| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | No | Effective Clinical Care |
Measure Description
Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge
Instruction
This measure is to be reported each time an infra-inguinal lower extremity is performed during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: ANY registry that includes anatomic details or CPT procedure codes and captures prescription of statin at hospital discharge as well as documented reasons for not prescribing statin medication is required to identify patients for numerator inclusion or denominator exclusion. The Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) and the Vascular Study Group of New England (VSGNE) are examples of registries that capture detailed anatomic information, but the measure is not limited to these registries.
Denominator
Patients who received an infra-inguinal lower extremity bypass
Denominator Criteria (Eligible Cases):
All patients aged 18 years and older
AND
Patient procedure during the performance period (CPT): 35556, 35566, 35570, 35571, 35583, 35585, 35587, 35656, 35666, 35671
Numerator
Patients prescribed a statin medication at discharge
Numerator Options:
Performance Met: Statin medication prescribed at discharge (G8816)
OR
Denominator Exception: Documented reason in the medical record for why the statin therapy was not prescribed (i.e. lower extremity bypass was for a patient with non-artherosclerotic disease) (G8815)
OR
Performance Not Met: Statin therapy not prescribed at discharge, reason not given (G8817)