Please complete this short form to comment on the recommendations on continued use of 21 Person-Centered Care, Wellness and Prevention, Chronic Conditions and Related Acute Events, and Safety measures in Centers for Medicare & Medicaid (CMS) programs.
These recommendations are the outcome of robust discussions from the virtual 2025 MSR Recommendation Group meeting held on October 6 and October 7, 2025.
How to Submit a Written Public Comment
- Select the measure (ID and title) from the drop-down menu.
- Attach additional documents to provide context to your comments, as needed.
- To comment on additional measures, please complete a new form for each.
Please Note
- Your name and organization will be displayed alongside your public comment once it is published.
- There may be a brief delay between the submission of your comment and its appearance online, as all comments undergo a review process to ensure compliance with our community guidelines. We appreciate your patience and understanding as we strive to maintain a respectful and engaging environment for everyone.
For additional information about the 2025 MSR Recommendation Group meeting, please also view the:
- MSR Recommendations Report
- MSR Recommendations Spreadsheet
- MSR Recommendation Group Meeting Summary
- Recordings from the two-day meeting (Day 1; Day 2).
To learn more about the MSR process, please see the Guidebook of Policies and Procedures for Pre-Rulemaking Measure Review and Measure Set Review.
Comments
Proposed Removal
On behalf of the American Heart Association (Association), including the American Stroke Association (ASA) and more than 35 million volunteers and supporters, we appreciate the opportunity to comment on Centers for Medicare & Medicaid Services Measure Set Review recommendations.
The Association does not agree with the Committee recommendation to remove the Joint Commission’s Discharged on Antithrombotic Therapy [00211-02-E-HIQR and 00211-02-E-PI] measure. The Association believes the measure should be maintained to address continued gaps. Xian et al., found a gap in care for patients who were not prescribed Dual Antiplatelet Therapy in alignment with guideline recommendations. (Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2794735)
Further regarding the Committee’s exception concerns, the Association believes existing measure exceptions allow for appropriate clinical decision-making in cases where antithrombotic therapy may be inappropriate.
Proposed Continued Use
On behalf of the American Heart Association (Association), including the American Stroke Association (ASA) and more than 35 million volunteers and supporters, we appreciate the opportunity to comment on Centers for Medicare & Medicaid Services Measure Set Review recommendations.
The Association notes that the American College of Cardiology and the Association’s Joint Committee on Performance Measures voted to retire Coronary Artery Disease (CAD): Antiplatelet Therapy [00178-01-C-MIPS] after PY2026. The MSR group noted the measure has shown consistently high performance and limited variation. Further there were suggestions made to update the measure to account for new evidence advances with concern there is no measure to replace the concept in CMS’ portfolio. The Association encourages the retirement of the measure due to the concerns noted by the group, and reiterates comments made during the meeting that if a gap in care is identified (backsliding) after the measure retirement the Association would re-evaluate new measures to address gaps in care at that time.
Support for Removal of CAD Antiplatelet Therapy, #006
The American College of Cardiology supports CMS and AHA’s plan to retire the CAD: Antiplatelet Therapy measure after PY2026, provided that CMS establishes a clear pathway to develop and implement an updated CAD antiplatelet therapy measure or broader CAD quality measures by 2028. While the existing measure is clinically important, its topped-out status and loss of stewardship limit its future utility. To prevent care gaps, we suggest that CMS prioritize development of modernized CAD measures that incorporate appropriate exclusions (frailty, anticoagulation, advanced illness) and address persistent disparities in antiplatelet access.
Antithrombotic Therapy for Secondary IS Prevention
The Joint Commission appreciates the opportunity to comment on the Measure Set Review recommendations for Discharged on Antithrombotic Therapy [00211-02-E-HIQR and 00211-02-E-PI]. The measure evaluates the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge in alignment with current clinical practice guidelines.1 It is currently in use by approximately 2,000 Joint Commission-certified stroke centers nationwide. The Joint Commission intends to maintain the chart-abstracted version of this measure for its Diseases-Specific Care Stroke Programs and will consider future revisions to refine the denominator population to better address clinical care gaps and improve quality outcomes.
Antithrombotic Therapy for Secondary IS Prevention
The Joint Commission appreciates the opportunity to comment on the Measure Set Review recommendations for Discharged on Antithrombotic Therapy [00211-02-E-HIQR and 00211-02-E-PI]. The measure evaluates the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge in alignment with current clinical practice guidelines.1 It is currently in use by approximately 2,000 Joint Commission-certified stroke centers nationwide. The Joint Commission intends to maintain the chart-abstracted version of this measure for its Diseases-Specific Care Stroke Programs and will consider future revisions to refine the denominator population to better address clinical care gaps and improve quality outcomes.