Do Not Cite. Draft for Work Group Review.

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1 D Nt Cite. Draft fr Wrk Grup Review. Pst-Acute Ischemic Strke Screening and Care Measure Bundle Measure Descriptin Percentage f patients aged 18 years and lder with a diagnsis f ischemic strke r transient ischemic attack within the last 3 mnths that received defect free care based upn their eligibility fr all 6 perfrmance measure cmpnents. Measure Cmpnents Numeratr Statement All eligible patients wh received all 6 measure cmpnents: Cmpnent 1: Bld Pressure Patients with a bld pressure <140/90 mmhg* OR Patients with a bld pressure 140/90 mmhg wh were: prescribed 2 r mre anti-hypertensive agents, referred back t PCP when BP nted t be >140/90 mmhg, OR medical ratinale dcumented (e.g., severe rthstasis) fr mre liberal bld pressure management. Cmpnent 2: Diabetes Screening Patient is screened fr Diabetes Mellitus with either fasting plasma glucse, HbA1C r ral glucse tlerance test during reprting perid Cmpnent 3: Apprpriate Antithrmbtic Patients aged 18 years and lder with ischemic strke n apprpriate antithrmbtic: Apprpriate antithrmbtic fr patients with strke AND nnvalvular atrial fibrillatin using therapeutic anticagulatin (warfarin, LMWH r direct factr inhibitrs as apprved by FDA), OR dcumentatin f medical/patient exceptin, Apprpriate antithrmbtic fr patients with strke AND mechanical heart valve r valvular atrial fibrillatin using anticagulatin with warfarin OR dcumentatin f medical/patient exceptin, OR Apprpriate antithrmbtic fr all ther patients with strke using antiplatelet r therapeutic anticagulatin If nt n antithrmbtic, referral t apprpriate prvider fr antithrmbtic management. Cmpnent 4: Tbacc Use Management Patients with strke wh have dcumentatin f active smking status OR frmer smker with quit date less than 1 year frm time f assessment prvided cunseling n the bad effects f tbacc, the benefit f quitting AND at least ne f the fllwing: Referral back t PCP fr tbacc cessatin supprt, AND/OR Referral t tbacc cessatin clinic r tbacc dependence telephne quitline, AND/OR Prescriptin f tbacc dependence medicatins including nictine replacement therapies prducts, buprpin SR r Varenicline, r any FDA-apprved drugs fr tbacc dependence therapies r referral t PCP Dcumentatin f never smker r frmer smker with quit date mre than a year frm time f assessment fulfills this cmpnent American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 51

2 D Nt Cite. Draft fr Wrk Grup Review. Denminatr Statement Denminatr Exceptins Exceptin Justificatin Supprting Guideline & Other References Cmpnent 5: Exercise Patients prescribed r cunseled n participating in an exercise prgram. Cmpnent 6: Depressin Patient is screened fr depressin using a validated instrument at least nce upn arrival at utpatient care (i.e. Beck Depressin Inventry, PHQ-9, Hamiltn Rating Scale fr Depressin) All patients aged 18 years and lder with a diagnsis f ischemic strke r transient ischemic attack (TIA) evaluated within three mnths n an ambulatry visit Fr all cmpnents: Patient declines treatment and screening Patient enrlled in a clinical trial Cntraindicatin dcumented Additinal exceptins fr individual cmpnents: Diabetes Screening: Nne Apprpriate Antithrmbtic: Nne Tbacc Use Management: Nne Exercise: Patients with dcumented cntraindicatin r physical inability t participate in an exercise prgram Depressin: Patients with aphasia r ther medical cnditin that precludes use f any validated screening tl Exceptins are warranted fr individuals enrlled in clinical trial as treatment plans required fr measure are nt clinically apprpriate fr these ppulatins interfering with clinical trials. Assessment and treatment cannt be prvided t thse wh refuse r leave AMA. Patients with dcumented cntraindicatin fr the specific interventin justifies exceptin as well. An exceptin was created fr exercise as medical cnditins may prevent meaningful cunseling n benefits. An exceptin was created fr depressin screening as sme patients may nt be able t fully engage in screening thrugh a validated tl due t neurlgical impairments. The fllwing clinical recmmendatin statements are quted verbatim frm the referenced clinical guidelines and represent the evidence base fr the measure: Cmpnent 1: Bld Pressure: Initiatin f BP therapy is indicated fr previusly untreated patients with ischemic strke r TIA wh, after the first several days, have an established BP 140 mm Hg systlic r 90 mm Hg diastlic (Class I; Level f Evidence B). Initiatin f therapy fr patients with BP <140 mm Hg systlic and <90 mm Hg diastlic is f uncertain benefit (Class IIb; Level f Evidence C). (Revised recmmendatin) (1) Resumptin f BP therapy is indicated fr previusly treated patients with knwn hypertensin fr bth preventin f recurrent strke and preventin f ther vascular events in thse wh have had an ischemic strke r TIA and are beynd the first several days (Class I; Level f Evidence A). (Revised recmmendatin) (1) Gals fr target BP level r reductin frm pretreatment baseline are uncertain and shuld be individualized, but it is reasnable t achieve a systlic pressure <140 mm Hg and a diastlic pressure <90 mm Hg (Class IIa; Level f Evidence B). Fr patients with a American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 52

3 D Nt Cite. Draft fr Wrk Grup Review American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. recent lacunar strke, it might be reasnable t target an SBP f <130 mm Hg (Class IIb; Level f Evidence B). (Revised recmmendatin) (1) Cmpnent 2: Diabetes Mellitus: Testing t assess risk fr future diabetes in asymptmatic peple shuld be cnsidered in adults f any age wh are verweight r bese (BMI 25 kg/m 2 r 23 kg/m 2 in Asian Americans) and wh have ne r mre additinal risk factrs fr diabetes. B (2) T test fr prediabetes, fasting plasma glucse, 2-h plasma glucse after 75-g ral glucse tlerance test, and A1C are equally apprpriate. B (2) Testing t detect type 2 diabetes in asymptmatic peple shuld be cnsidered in adults f any age wh are verweight r bese (BMI 25 kg/m 2 r 23 kg/m 2 in Asian Americans) and wh have ne r mre additinal risk factrs fr diabetes. B (2) T test fr type 2 diabetes, fasting plasma glucse, 2-h plasma glucse after 75-g ral glucse tlerance test, and A1C are equally apprpriate. B (2) Disrders f Glucse Metablism and DM Recmmendatins.After a TIA r ischemic strke, all patients shuld prbably be screened fr DM with testing f fasting plasma glucse, HbA1c, r an ral glucse tlerance test. Chice f test and timing shuld be guided by clinical judgment and recgnitin that acute illness may temprarily perturb measures f plasma glucse. In general, HbA1c may be mre accurate than ther screening tests in the immediate pstevent perid (Class IIa; Level f Evidence C). (New recmmendatin) (1) Use f existing guidelines frm the ADA fr glycemic cntrl and cardivascular risk factr management is recmmended fr patients with an ischemic strke r TIA wh als have DM r pre- DM (Class I; Level f Evidence B). (1) Cmpnent 3: Apprpriate Antithrmbtic: Apprpriate antithrmbtic fr patients with AF r mechanical heart valve: VKA therapy (Class I; Level f Evidence A), apixaban (Class I; Level f Evidence A), and dabigatran (Class I; Level f Evidence B) are all indicated fr the preventin f recurrent strke in patients with nnvalvular AF, whether parxysmal r permanent. The selectin f an antithrmbtic agent shuld be individualized n the basis f risk factrs, cst, tlerability, patient preference, ptential fr drug interactins, and ther clinical characteristics, including renal functin and time in INR therapeutic range if the patient has been taking VKA therapy. (1) Rivarxaban is reasnable fr the preventin f recurrent strke in patients with nnvalvular AF (Class IIa; Level f Evidence B). (1) Fr patients with ischemic strke r TIA and AF wh are unable t take ral anticagulants, aspirin alne is recmmended (Class I; Level f Evidence A). (1) 53

4 D Nt Cite. Draft fr Wrk Grup Review. The additin f clpidgrel t aspirin therapy, cmpared with aspirin therapy alne, might be reasnable (Class IIb; Level f Evidence B). (1) Fr mst patients with a strke r TIA in the setting f AF, it is reasnable t initiate ral anticagulatin within 14 days after the nset f neurlgical symptms (Class IIa; Level f Evidence B). (1) In the presence f high risk fr hemrrhagic cnversin (ie, large infarct, hemrrhagic transfrmatin n initial imaging, uncntrlled hypertensin, r hemrrhage tendency), it is reasnable t delay initiatin f ral anticagulatin beynd 14 days (Class IIa; Level f Evidence B). (1) Fr patients with ischemic strke r TIA wh have rheumatic mitral valve disease and AF, lngterm VKA therapy with an INR target f 2.5 (range, ) is recmmended (Class I; Level f Evidence A). (1) Fr patients with a mechanical artic valve and a histry f ischemic strke r TIA befre its insertin, VKA therapy is recmmended with an INR target f 2.5 (range, ) (Class I; Level f Evidence B). (1) Fr patients with a mechanical mitral valve and a histry f ischemic strke r TIA befre its insertin, VKA therapy is recmmended with an INR target f 3.0 (range, ) (Class I; Level f Evidence C). (1) Apprpriate antithrmbtic fr all ther strke patients: Fr patients with nncardiemblic ischemic strke r TIA, the use f antiplatelet agents rather than ral anticagulatin is recmmended t reduce the risk f recurrent strke and ther cardivascular events (Class I; Level f Evidence A). (1) Aspirin ( mg/d) mntherapy (Class I; Level f Evidence A) r the cmbinatin f aspirin 25 mg and extended-release dipyridamle 200 mg twice daily (Class I; Level f Evidence B) is indicated as initial therapy after TIA r ischemic strke fr preventin f future strke. (1) Clpidgrel (75 mg) mntherapy is a reasnable ptin fr secndary preventin f strke in place f aspirin r cmbinatin aspirin/dipyridamle (Class IIa; Level f Evidence B). This recmmendatin als applies t patients wh are allergic t aspirin. (1) Cmpnent 4: Tbacc Use Management: Patients Healthcare prviders shuld strngly advise every patient with strke r TIA wh has smked in the past year t quit (Class I; Level f Evidence C). (1) It is reasnable t advise patients after TIA r ischemic strke t avid envirnmental (passive) tbacc smke (Class IIa; Level f Evidence B). (1) Cunseling, nictine prducts, and ral smking cessatin medicatins are effective in helping smkers t quit (Class I; Level f Evidence A). (1) American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 54

5 D Nt Cite. Draft fr Wrk Grup Review. It is essential that clinicians and health care delivery systems cnsistently identify and dcument tbacc use status and treat every tbacc user seen in a health care setting. (3) Individual, grup, and telephne cunseling are effective, and their effectiveness increases with treatment intensity. (3) Numerus effective medicatins are available fr tbacc dependence, and clinicians shuld encurage their use by all patients attempting t quit smking except when medically cntraindicated r with specific ppulatins fr which there is insufficient evidence f effectiveness (i.e., pregnant wmen, smkeless tbacc users, light smkers, and adlescents). (3) Cunseling and medicatin are effective when used by themselves fr treating tbacc dependence. The cmbinatin f cunseling and medicatin, hwever, is mre effective than either alne. Thus, clinicians shuld encurage all individuals making a quit attempt t use bth cunseling and medicatin. (3) Telephne quitline cunseling is effective with diverse ppulatins and has brad reach. Therefre, clinicians and health care delivery systems shuld bth ensure patient access t quitlines and prmte quitline use. (3) Cmpnent 5: Exercise: Physical activity and exercise prescriptin shuld be incrprated int the management f strke survivrs. The prmtin f physical activity in strke survivrs shuld emphasize lw- t mderate-intensity aerbic activity, musclestrengthening activity, reductin f sedentary behavir, and risk management fr secndary preventin f strke. (4) After successful screening, an individually tailred exercise prgram is indicated t enhance cardirespiratry fitness and t reduce the risk f strke recurrence. (Class I; Level A (fr imprved fitness); Level B (fr reductin f strke risk)(5) Cmpnent 6: Depressin: All patients with strke shuld be screened fr depressive symptms, given the high prevalence f depressin pststrke, the need fr screening t detect depressin, and the strng evidence fr treating symptmatic depressin pststrke (Evidence Level B). (6) Screening shuld be undertaken using a validated tl t maximize detectin f depressin (Evidence Level B); table 1A a summary f suggested validated tls is available at Screening fr PSD may take place at varius stages thrughut the cntinuum f strke care, particularly at transitin pints (Evidence Level C). Repeated screening may be required since the ideal timing fr screening fr PSD is unclear. (6) Screening fr depressive symptms shuld be cnsidered during transitin pints in care, such as frm an inpatient acute setting t an inpatient rehabilitatin setting, and r [sic] befre return t the cmmunity (Evidence Level C). (6) American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 55

6 D Nt Cite. Draft fr Wrk Grup Review. Relatinship t Desired Outcme Measure Imprtance Screening fr depressive symptms shuld be cnsidered fllwing discharge t the cmmunity, at strke preventin clinic assessments, during fllw-up appintments, and during peridic health assessments with primary care practitiners and cnsulting specialists (Evidence Level C). (6) Bld Pressure: Treatment f hypertensin is cnsidered t be amng the mst imprtant interventins fr secndary preventin f ischemic strke. Defined as a systlic bld pressure (SBP) 140 mm Hg r a diastlic bld pressure (DBP) 90 mm Hg, an estimated 78 millin Americans have hypertensin. The prevalence amng patients with a recent ischemic strke is 70%. The risk fr a first ischemic strke is directly related t bld pressure (BP) starting with an SBP as lw as 115 mm Hg. Diabetes Mellitus: Diabetes mellitus, defined by elevated glycemic markers, is a majr risk factr fr cardivascular disease (CVD), which is the mst cmmn cause f death amng adults with diabetes mellitus, underscring the need fr aggressive CVD risk factr management, nting that evidence is lacking that treatment f diabetes specifically reduces risk f recurrent strke. Antithrmbtic Therapy: Apprpriate use f antithrmbtic therapy reduces the risk f recurrent strke. Smking Cessatin: Cigarette smking is an imprtant independent risk factr fr first ischemic strke and cntributes t an increased risk fr silent brain infarctin. It is als assciated with a substantially increased risk fr strke recurrence in the elderly, nting that risk fr recurrent strke in yunger ppulatins is less well dcumented. Exercise: Physical inactivity after strke is highly prevalent. The assessed bdy f evidence clearly supprts the use f exercise training (bth aerbic and strength training) fr strke survivrs.(5) Exercise training imprves functinal capacity, the ability t perfrm activities f daily living, and quality f life, and it reduces the risk fr subsequent cardivascular events.(4) Opprtunity fr Imprvement Depressin: Pststrke depressin impedes recvery and results in wrse lngterm utcmes. There is need fr a system f care that ensures screening fr pststrke depressin as a standard and cnsistent cmpnent f clinical practice acrss settings as strke patients transitin frm acute care t active rehabilitatin and reintegratin int their cmmunity. Pharmaclgical treatment has been assciated with a reductin f depressive symptmatlgy. Despite the imprtance f each f these cmpnents it is anticipated that prviders can imprve quality f care prvided by evaluating glbal perfrmance n care prvided fllwing a strke. The wrk grup ntes that individual cmpnents may ccur acrss utpatient care team and intent was fr prvider t meet criteria if care cmpnents were crdinated with apprpriate specialist r primary care prvider American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 56

7 D Nt Cite. Draft fr Wrk Grup Review. Natinal Quality Strategy Dmains Harmnizatin with Existing Measures Measure Purpse (Check all that apply) Type f Measure (Check all that apply) Level f Measurement (Check all that apply) Care Setting (Check all that apply) Patient and Family Engagement Patient Safety Care Crdinatin Ppulatin/Public Health Efficient Use f Healthcare Resurces Clinical Prcess/Effectiveness The definitins and specificatins used in the cmpnents f this measure are similar t thse cllected in the cmmnly emplyed strke measures (i.e., CMS, Jint Cmmissin and/r AHA/ASA), ensuring parsimny in data cllectin strategies. A separate measure is being created t mnitr glbal perfrmance fr quality imprvement. NQF #18/PQRS #2326 Cntrlling High Bld Pressure cmpnent is similar with additinal specificatin added t allw referral/crdinatin with Primary Care Prvider t meet measure cmpsite. NQF Measure #0057 Cmprehensive Diabetes Care: Hemglbin A1c (HbA1c) testing and #0059 Cmprehensive Diabetes Care: Hemglbin A1c (HbA1c) Pr Cntrl (>9.0%) were mdified t include patients in the denminatr beynd thse diagnsed diabetes mellitus. NQF#0435 and #3042 STK 02: Discharged n Antithrmbtic Therapy is similar with additinal specificatin added t allw referral/crdinatin with apprpriate health care prvider t meet measure cmpsite. NQF #0028/PQRS #226 Preventive Care and Screening: Tbacc Use: Screening and Cessatin is similar with additinal specificatin added t allw referral/crdinatin with Primary Care Prvider t meet measure cmpsite. NQF #0103/PQRS# 325 Adult Majr Depressive Disrder: Cmprehensive Depressin Evaluatin: Diagnsis and Severity is a treatment measure fr patients with Majr Depressive Disrder. NQF #0518 Depressin Assessment Cnducted is intended fr hme health services. NQF #0711 Depressin Remissin at Six Mnths, NQF #0710 Depressin Remissin at Twelve Mnths are treatment measures fr patients with depressin identified. The wrk grup develped this depressin cmpnent t capture screening fr pststrke depressin in the utpatient setting. Quality imprvement Accuntability Prcess Outcme Structure Individual Prvider Practice System Emergency Departments Inpatient Outpatient Skilled Nursing Hme American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 57

8 D Nt Cite. Draft fr Wrk Grup Review. Data Surce (Check all that apply) Electrnic health recrd (EHR) data Administrative Data/Claims Chart Review Registry References 1. Kernan WN, Ovbiagele B, Black HR, et al; n behalf f the American Heart Assciatin Strke Cuncil, Cuncil n Cardivascular and Strke Nursing, Cuncil n Clinical Cardilgy, and Cuncil n Peripheral Vascular Disease. Guidelines fr the preventin f strke in patients with strke and transient ischemic attack: a guideline fr healthcare prfessinals frm the American Heart Assciatin/American Strke Assciatin. Strke. 2014;45: American Diabetes Assciatin. Classificatin and Diagnsis f Diabetes. Diabetes Care 2016;39(S1):S13-S US Department f Health and Human Services. Treating tbacc use and dependence: 2008 Update. Am J Prev Med. 2008;35(2): Billinger SA, Arena R, Bernhardt J, et al; n behalf f the American Heart Assciatin Strke Cuncil, Cuncil n Cardivascular and Strke Nursing, Cuncil n Lifestyle and Cardimetablic Health, Cuncil n Epidemilgy and Preventin, and Cuncil n Clinical Cardilgy. Physical activity and exercise recmmendatins fr strke survivrs: a statement fr healthcare prfessinals frm the American Heart Assciatin/American Strke Assciatin. Strke. 2014;45: Winstein CJ, Stein J, Arena R, et al.; n behalf f the American Heart Assciatin Strke Cuncil, Cuncil n Cardivascular and Strke Nursing, Cuncil n Clinical Cardilgy, and Cuncil n Quality f Care and Outcmes Research. Guidelines fr adult strke rehabilitatin and recvery: a guideline fr healthcare prfessinals frm the American Heart Assciatin/American Strke Assciatin. Strke. 2016;47:e98 e Eskes GA, Lanctôt KL, Herrmann N, et al. Canadian Strke Best Practice Recmmendatins: Md, Cgnitin and Fatigue Fllwing Strke practice guidelines, update Int J Strke. 2015;10(7): American Academy f Neurlgy Institute. All Rights Reserved. CPT Cpyright American Medical Assciatin. 58

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