Statin Prescribed at Discharge

Acute myocardial infarction (AMI) patients who are prescribed a statin at hospital discharge.

Measure specifications are in the Public Domain
CPT(R) is a trademark of the American Medical Association. Current Procedural Terminology. (CPT) is copyright 2012 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
 
LOINC(R) is a registered trademark of the Regenstrief Institute.
 

This material contains SNOMED Clinical Terms (R) (SNOMED CT(c)) copyright 2004-2010 International Health Terminology Standards Development Organization. All rights reserved.

Several randomized clinical trials have proven the benefits of statin drugs (also known as HMG Co-A reductase inhibitors) in reducing the risk of death and recurrent cardiovascular events in a broad range of patients with established cardiovascular disease, including those with prior myocardial infarction (4S, 1994; Sacks, 1996; LIPID Study Group, 1998; and MRC/BHF Heart Protection Study, 2002). Current ACC/AHA guidelines place a strong emphasis on the initiation or maintenance of statin drugs for patients hospitalized with AMI, particularly those with LDL-cholesterol levels above 100 mg/dL (Smith, 2011; Anderson, 2007; and O'Gara, 2013). As a result of the strength of the evidence and guideline support, the ACC/AHA have developed a performance measure to assess this aspect of care for patients with acute myocardial infarction (Krumholz, 2008). Because statins are generally well-tolerated, most patients with AMI are appropriate candidates for this therapy.

Several randomized clinical trials have proven the benefits of statin drugs (also known as HMG Co-A reductase inhibitors) in reducing the risk of death and recurrent cardiovascular events in a broad range of patients with established cardiovascular disease, including those with prior myocardial infarction.

An increase in rate.

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1–157.

Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99.

The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349-57.

MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:7-22.

O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:485–510.

Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383-9.

Sacks FM, Pfeffer MA, Moye LA, et al, for the Cholesterol and Recurrent Events Trial investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996;335:1001-9.

Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458–2473.

Exclusion element guidance: 
The intent for the exclusion for patients who are clinical trial participants was to be limited to patients participating in a clinical trial for acute myocardial infarction (AMI), ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (non-STEMI), heart attack, or acute coronary syndrome (ACS), the same conditions as covered by the measure. However, the value set specifying clinical trial participation is not limited to a specific type of trial. 

Medical or patient reasons for not performing a test or giving a medication are categories for valid medical or patient reasons that are not specifically listed in the exclusion section of the measure. Each is expected to be captured and made available for measurement or clinical decision support within the EHR workflow but the exact method or location of capture is a local or vendor decision.

All hospital discharges for acute myocardial infarction (AMI) with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission.

Patients age 18 and older with an ICD-9-CM Principal Diagnosis Code for Acute Myocardial Infarction (AMI).

•	Patients with Comfort Measures Only documented
•	Patients enrolled in clinical trials
•	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

AMI patients who are prescribed a statin medication at hospital discharge.

Patients with LDL less than 100 mg/dL within the first 24 hours after hospital arrival or 30 days prior to hospital arrival and not discharged on a statin.

Patients with a documented Reason for Not Prescribing Statin Medication at Discharge. This includes patients with a statin allergy, patients with a hold on the administration of statin medications, and patients with a medical or patient reason for not prescribing this medication.

For every patient evaluated by this measure also identify payer, race, ethnicity, and sex.

Initial Patient Population =
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
- AND: "Diagnosis, Active: Hospital Measures - AMI (ordinality: 'Principal')" starts during "Occurrence A of Encounter, Performed: Encounter Inpatient"
- AND: "Occurrence A of Encounter, Performed: Encounter Inpatient (length of stay <= 120 day(s))"
- AND: "Occurrence A of Encounter, Performed: Encounter Inpatient" ends during "Measurement Period"
Denominator =
- AND: "Initial Patient Population"
Denominator Exclusions =
- AND:
  - OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Patient Expired')"
  - OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Discharge To Another Hospital')"
  - OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Discharged to Home for Hospice Care')"
  - OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Discharged to Health Care Facility for Hospice Care')"
  - OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Left Against Medical Advice')"
  - OR:
    - AND: "Occurrence A of Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Occurrence A of Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
    - AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts during "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" ends before start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
    - AND: "Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" starts before or during "Occurrence A of Encounter, Performed: Emergency Department Visit"
Numerator =
- AND: "Medication, Discharge: Statin" starts during "Occurrence A of Encounter, Performed: Encounter Inpatient"
Denominator Exceptions =
- AND:
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND: "Laboratory Test, Result: LDL-c Test (result < 100 mg/dL)" <= 24 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
  - OR:
    - AND: "Laboratory Test, Result: LDL-c Test (result < 100 mg/dL)" <= 24 hour(s) starts after start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND: "Laboratory Test, Result: LDL-c Test (result < 100 mg/dL)" <= 30 day(s) starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
  - OR:
    - AND: "Laboratory Test, Result: LDL-c Test (result < 100 mg/dL)" <= 30 day(s) starts before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND: "Medication, Administered not done: Hospital Measures - Hold" for "Statin " starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
    - AND: "Medication, Administered not done: Hospital Measures - Hold" for "Statin " starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - OR: "Medication, Order not done: Medical Reason" for "Statin ingredient specific "
    - OR: "Medication, Order not done: Patient Refusal" for "Statin ingredient specific "
    - OR: "Medication, Discharge not done: Medical Reason" for "Statin ingredient specific "
    - OR: "Medication, Discharge not done: Patient Refusal" for "Statin ingredient specific "
    - OR: "Medication, Allergy: Statin Allergen"
    - starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"
  - OR:
    - AND: "Medication, Administered not done: Hospital Measures - Hold" for "Statin " starts during "Occurrence A of Encounter, Performed: Encounter Inpatient"
    - AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"

"Diagnosis, Active: Hospital Measures - AMI" using "Hospital Measures - AMI Grouping Value Set (2.16.840.1.113883.3.666.5.3011)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"
"Intervention, Performed: Comfort Measures " using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"
"Laboratory Test, Result: LDL-c Test" using "LDL-c Test SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.799)"
"Medication, Administered not done: Hospital Measures - Hold" using "Hospital Measures - Hold SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.1145)"
"Medication, Administered: Statin" using "Statin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.225)"
"Medication, Allergy: Statin Allergen" using "Statin Allergen RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.423)"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Discharge: Statin" using "Statin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.225)"
"Medication, Discharge: Statin ingredient specific" using "Statin ingredient specific RXNORM Value Set (2.16.840.1.113762.1.4.1021.7)"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Order: Statin ingredient specific" using "Statin ingredient specific RXNORM Value Set (2.16.840.1.113762.1.4.1021.7)"
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
"Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" using "Clinical Trial Participant SNOMEDCT Value Set (2.16.840.1.113883.3.526.2.643)"
Attribute: "Discharge status: Discharge To Another Hospital" using "Discharge To Another Hospital SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.87)"
Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"
Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"
Attribute: "Ordinality: Principal" using "Principal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.14)"
Attribute: "Discharge status: Patient Expired" using "Patient Expired SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.309)"
Attribute: "Discharge status: Left Against Medical Advice" using "Left Against Medical Advice SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.308)"

"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"

Acute Myocardial Infarction (AMI)

eMeasure Title	Statin Prescribed at Discharge
eMeasure Identifier (Measure Authoring Tool)	30	eMeasure Version number	4
NQF Number	0639	GUID	ebfa203e-acc1-4228-906c-855c4bf11310
Measurement Period	January 1, 20xx through December 31, 20xx
Measure Steward	Centers for Medicare & Medicaid Services
Measure Developer	Oklahoma Foundation for Medical Quality
Endorsed By	National Quality Forum
Description	Acute myocardial infarction (AMI) patients who are prescribed a statin at hospital discharge.
Copyright	Measure specifications are in the Public Domain CPT(R) is a trademark of the American Medical Association. Current Procedural Terminology. (CPT) is copyright 2012 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. LOINC(R) is a registered trademark of the Regenstrief Institute. This material contains SNOMED Clinical Terms (R) (SNOMED CT(c)) copyright 2004-2010 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer	None
Measure Scoring	Proportion
Measure Type	Process
Stratification	None
Risk Adjustment	None
Rate Aggregation	None
Rationale	Several randomized clinical trials have proven the benefits of statin drugs (also known as HMG Co-A reductase inhibitors) in reducing the risk of death and recurrent cardiovascular events in a broad range of patients with established cardiovascular disease, including those with prior myocardial infarction (4S, 1994; Sacks, 1996; LIPID Study Group, 1998; and MRC/BHF Heart Protection Study, 2002). Current ACC/AHA guidelines place a strong emphasis on the initiation or maintenance of statin drugs for patients hospitalized with AMI, particularly those with LDL-cholesterol levels above 100 mg/dL (Smith, 2011; Anderson, 2007; and O'Gara, 2013). As a result of the strength of the evidence and guideline support, the ACC/AHA have developed a performance measure to assess this aspect of care for patients with acute myocardial infarction (Krumholz, 2008). Because statins are generally well-tolerated, most patients with AMI are appropriate candidates for this therapy.
Clinical Recommendation Statement	Several randomized clinical trials have proven the benefits of statin drugs (also known as HMG Co-A reductase inhibitors) in reducing the risk of death and recurrent cardiovascular events in a broad range of patients with established cardiovascular disease, including those with prior myocardial infarction.
Improvement Notation	An increase in rate.
Reference	Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1–157.
Reference	Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99.
Reference	The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349-57.
Reference	MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:7-22.
Reference	O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:485–510.
Reference	Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383-9.
Reference	Sacks FM, Pfeffer MA, Moye LA, et al, for the Cholesterol and Recurrent Events Trial investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996;335:1001-9.
Reference	Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458–2473.
Definition	None
Guidance	Exclusion element guidance: The intent for the exclusion for patients who are clinical trial participants was to be limited to patients participating in a clinical trial for acute myocardial infarction (AMI), ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (non-STEMI), heart attack, or acute coronary syndrome (ACS), the same conditions as covered by the measure. However, the value set specifying clinical trial participation is not limited to a specific type of trial. Medical or patient reasons for not performing a test or giving a medication are categories for valid medical or patient reasons that are not specifically listed in the exclusion section of the measure. Each is expected to be captured and made available for measurement or clinical decision support within the EHR workflow but the exact method or location of capture is a local or vendor decision.
Transmission Format	None
Initial Patient Population	All hospital discharges for acute myocardial infarction (AMI) with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission.
Denominator	Patients age 18 and older with an ICD-9-CM Principal Diagnosis Code for Acute Myocardial Infarction (AMI).
Denominator Exclusions	• Patients with Comfort Measures Only documented • Patients enrolled in clinical trials • 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
Numerator	AMI patients who are prescribed a statin medication at hospital discharge.
Numerator Exclusions	None
Denominator Exceptions	Patients with LDL less than 100 mg/dL within the first 24 hours after hospital arrival or 30 days prior to hospital arrival and not discharged on a statin. Patients with a documented Reason for Not Prescribing Statin Medication at Discharge. This includes patients with a statin allergy, patients with a hold on the administration of statin medications, and patients with a medical or patient reason for not prescribing this medication.
Measure Population	Not applicable
Measure Observations	Not applicable
Supplemental Data Elements	For every patient evaluated by this measure also identify payer, race, ethnicity, and sex.

Table of Contents

Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements