#257: Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

Quality ID

257

NQF

1519

High Priority Measure

No

Specifications

Registry

Measure Type

Process

Specialty

Vascular Surgery

Measure description

Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge

 

Instructions

This measure is to be submitted each time an infra-inguinal lower extremity is performed during the performance period. This measure may be submitted 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.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

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)

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