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Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Ischemic Stroke Hospitalization with Claims-Based Risk Adjustment for Stroke Severity

CBE ID
4595
Endorsement Status
1.0 New or Maintenance
Is Under Review
Yes
Next Maintenance Cycle
Fall 2024
1.6 Measure Description

The measure estimates the hospital-level, risk-standardized mortality rate (RSMR) for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage[MA]) discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure includes the National Institutes of Health (NIH) Stroke Scale as an assessment of stroke severity upon admission in the risk-adjustment model.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.10 Measure Rationale

The goal of a stroke mortality measure* is to improve patient outcomes for patients hospitalized with acute ischemic stroke by providing patients, physicians, hospitals, and policymakers with hospital-level, risk-standardized mortality rates. Measurement of patient outcomes allows for a broad view of quality of care that encompasses more than what can be captured by individual process-of-care measures. 

Stroke occurs in nearly a million people in the United States annually (CDC, 2020), is a common cause of death, and is a leading cause of disability (American Stroke Association, 2024). As the fifth-leading cause of death, stroke affects approximately 795,000 people in the United States annually (Tsao et al., 2023). Additionally, stroke accounted for 17.5% of all cardiovascular disease deaths in the U.S. in 2022 (National Center for Health Statistics, 2024).  

Stroke mortality is an appropriate measure of the quality of care; stroke mortality rates vary across hospitals and can be influenced by the quality of care during the initial hospitalization; mortality following stroke is an important adverse outcome that can be measured reliably and objectively. Specifically, post-stroke mortality rates have been shown to be influenced by critical and modifiable aspects of care such as response to complications, timeliness of delivery of care, organization of care, and appropriate imaging (Bekelis et al., 2016; Bustamante et al., 2016; Xian et al., 2019; Jahan et al., 2019, Kuriakose & Xiao, 2020, Lip et al., 2020; Feigin & Owolabi, 2023). 

*Note: There are two existing CMS stroke mortality measures that are referenced in this CBE submission: an existing measure that is publicly reported (and includes only Medicare Fee-For-Service [FFS] patients) and this (new) measure under review, which is a re-specification of the existing publicly reported measure. We define them below and provide nomenclature to differentiate them. 

FFS-only stroke mortality measure” is used to describe the measure that is currently publicly reported on Care Compare. This three-year measure includes only Medicare FFS admissions. This measure includes the NIH stroke scale (NIHSS) in the risk adjustment model. In the attachment, we provide the methodology report for the FFS-only measure, which is also available online on QualityNet

https://qualitynet.cms.gov/files/663be566cc07c26dc8485e00?filename=2024_CSM_AUS_Report_v1.0.pdf 

Stroke Mortality measure” is used to indicate the new measure submitted in this CBE endorsement application, which is a re-specified version of the FFS-only measure. The Stroke Mortality measure is now a two-year measure, includes both Medicare Advantage (MA) and Medicare FFS admissions, includes the NIHSS in the risk adjustment model, and has an updated risk model (newly selected risk variables). 

References 

American Stroke Association. (2024). About stroke. Retrieved from https://www.stroke.org/en/about-stroke 

Bekelis K, Marth NJ, Wong K, Zhou W, Birkmeyer JD, Skinner J. Primary stroke center hospitalization for elderly patients with stroke: implications for case fatality and travel times. JAMA Internal Medicine. 2016;176(9):1361-1368. 

Bustamante, A., García-Berrocoso, T., Rodriguez, N., Llombart, V., Ribó, M., Molina, C., & Montaner, J. (2016). Ischemic stroke outcome: A review of the influence of post-stroke complications within the different scenarios of stroke care. European Journal of Internal Medicine, 29, 9-21. https://doi.org/10.1016/j.ejim.2015.11.030 

Centers for Disease Control and Prevention: Stroke. Available at: https://www.cdc.gov/stroke/index.htm. 

Feigin, V. L., & Owolabi, M. O., on behalf of the World Stroke Organization–Lancet Neurology Commission Stroke Collaboration Group. (2023). Pragmatic solutions to reduce the global burden of stroke: A World Stroke Organization–Lancet Neurology Commission. The Lancet Neurology, 22(12), 1160–1206. https://doi.org/10.1016/S1474-4422(23)00289-6 

Jahan R, Saver JL, Schwamm LH, et al. Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice. JAMA. 2019;322(3):252-263. 

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and treatment of stroke: Present status and future perspectives. International Journal of Molecular Sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609 

Lip, G. Y. H., Lane, D. A., Lenarczyk, R., Boriani, G., Doehner, W., Benjamin, L. A., Fisher, M., Lowe, D., Sacco, R. L., Schnabel, R., Watkins, C., Ntaios, G., & Potpara, T. (2022). Integrated care for optimizing the management of stroke and associated heart disease: A position paper of the European Society of Cardiology Council on Stroke. European Heart Journal, 43(26), 2442–2460. https://doi.org/10.1093/eurheartj/ehac245 

National Center for Health Statistics. Multiple Cause of Death 2018–2022 on CDC WONDER Database. https://wonder.cdc.gov/mcd.html 

Tsao, C. W., Aday, A. W., Almarzooq, Z. I., et al. (2023). Heart disease and stroke statistics—2023 update: A report from the American Heart Association. Circulation, 147, e93–e621. https://doi.org/10.1161/CIR.0000000000001123 

Xian Y, Xu H, O'Brien EC, et al. Clinical effectiveness of direct oral anticoagulants vs warfarin in older patients with atrial fibrillation and ischemic stroke: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. JAMA. 2019;322(3):252-263. 

1.20 Types of Data Sources
1.25 Data Source Details

Medicare fee-for-service (FFS) claims and Medicare Advantage (MA) encounters, in addition to Medicare administrative data, are used to derive all components of the measure.