+-----+-------+-----------+------------+------+---------------------+
| **P | **As  | **Desc    | **Codes**  | **   | **Definition**      |
| ati | sessm | ription** |            | Resu |                     |
| ent | ent** |           |            | lt** |                     |
| I   |       |           |            |      |                     |
| D** | **    |           |            |      |                     |
|     | Varia |           |            |      |                     |
|     | ble** |           |            |      |                     |
+-----+-------+-----------+------------+------+---------------------+
|     | **    | Was the   | 1: Yes     |      | **Note:** Patients  |
|     | STROK | patient   |            |      | discharged to a     |
|     | EDC** | d         | 2: No      |      | rehabilitation      |
|     |       | ischarged |            |      | facility, ECF, SNF, |
|     |       | to home   | If No, the |      | intermediate care,  |
|     |       | or to a   | patient is |      | or long-term care   |
|     |       | rehabi    | excluded   |      | hospital are        |
|     |       | litation, | from this  |      | included in this    |
|     |       | int       | measure.   |      | measure.            |
|     |       | ermediate |            |      |                     |
|     |       | or        |            |      | Patients discharged |
|     |       | long-term |            |      | to another facility |
|     |       | care      |            |      | for inpatient acute |
|     |       | facility? |            |      | care or to hospice, |
|     |       |           |            |      | who leave against   |
|     |       |           |            |      | medical advice, or  |
|     |       |           |            |      | who die prior to    |
|     |       |           |            |      | discharge are       |
|     |       |           |            |      | excluded from this  |
|     |       |           |            |      | measure.            |
+-----+-------+-----------+------------+------+---------------------+
|     | **    | Is there  | 1: Yes     |      | Comfort measures    |
|     | COMFO | docu      |            |      | only (code 1)       |
|     | NLY** | mentation | 2: No      |      | includes referrals  |
|     |       | by a      |            |      | to palliative care, |
|     |       | p         | If Yes,    |      | hospice.            |
|     |       | hysician, | the        |      |                     |
|     |       | APN, or   | patient is |      | Patients with a DNR |
|     |       | PA of     | excluded   |      | order are NOT coded |
|     |       | comfort   | from this  |      | 1 unless there is a |
|     |       | measures  | measure.   |      | specific order for  |
|     |       | only      |            |      | comfort measures.   |
|     |       | during    |            |      |                     |
|     |       | the       |            |      |                     |
|     |       | hospital  |            |      |                     |
|     |       | stay?     |            |      |                     |
+-----+-------+-----------+------------+------+---------------------+
|     | *     | Was an    | 1.  Yes    |      | Direct and          |
|     | *LDLH | LDL-C of  |            |      | calculated LDL-c    |
|     | IGH** | \> 100    | 2.  No     |      | values are          |
|     |       | obtained  |            |      | acceptable.         |
|     |       | either    | If yes,    |      |                     |
|     |       | during    | the        |      |                     |
|     |       | the       | patient is |      |                     |
|     |       | hospital  | included   |      |                     |
|     |       | stay or   | in this    |      |                     |
|     |       | within 30 | measure.   |      |                     |
|     |       | days      |            |      |                     |
|     |       | prior to  |            |      |                     |
|     |       | a         |            |      |                     |
|     |       | dmission? |            |      |                     |
+-----+-------+-----------+------------+------+---------------------+
|     | **ONC | Was the   | 1.  Yes    |      | **[Lipid-lowering   |
|     | HOL** | patient   |            |      | Medicat             |
|     |       | on a      | 2.  No     |      | ions]{.underline}** |
|     |       | lipid     |            |      |                     |
|     |       | -lowering | If yes,    |      | **HMG-CoA Reductase |
|     |       | m         | the        |      | Inhibitors          |
|     |       | edication | patient is |      | (Statins):**        |
|     |       | at the    | included   |      | fluvastatin sodium  |
|     |       | time of   | in this    |      | (Lescol),           |
|     |       | admission | measure.   |      | atorvastatin        |
|     |       | (r        |            |      | calcium (Lipitor),  |
|     |       | egardless |            |      | lovastatin          |
|     |       | of LDL-C  |            |      | (Mevacor)           |
|     |       | level)?   |            |      | (Altocor),          |
|     |       |           |            |      | pravastatin sodium  |
|     |       |           |            |      | (Pravacol),         |
|     |       |           |            |      | simvastatin         |
|     |       |           |            |      | (Zocor),            |
|     |       |           |            |      | rosuvastatin        |
|     |       |           |            |      | calcium (Crestor)   |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Cholesterol       |
|     |       |           |            |      | absorption          |
|     |       |           |            |      | inhibitors**:       |
|     |       |           |            |      | ezetimibe (Zetia)   |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Combination**:    |
|     |       |           |            |      | ez                  |
|     |       |           |            |      | etimibe/simvastatin |
|     |       |           |            |      | (Vytorin),          |
|     |       |           |            |      | Niaspan/lovastatin  |
|     |       |           |            |      | (Advicor)           |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Nicotinic Acid:** |
|     |       |           |            |      | niacin extended     |
|     |       |           |            |      | release tablets     |
|     |       |           |            |      | (Niaspan),          |
|     |       |           |            |      | Crystalline niacin, |
|     |       |           |            |      | sustained or timed  |
|     |       |           |            |      | release niacin      |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Bile Acid         |
|     |       |           |            |      | Sequestran          |
|     |       |           |            |      | ts**[:]{.underline} |
|     |       |           |            |      | colestipol          |
|     |       |           |            |      | hydrochloride       |
|     |       |           |            |      | (Colestid),         |
|     |       |           |            |      | colesevelam         |
|     |       |           |            |      | hydrochloride       |
|     |       |           |            |      | (Welchol),          |
|     |       |           |            |      | cholestyramine      |
|     |       |           |            |      | (Questran)          |
|     |       |           |            |      | (Locholest)         |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Fibrates**:       |
|     |       |           |            |      | clofibrate          |
|     |       |           |            |      | (Atromid-S)         |
|     |       |           |            |      | (Abitrate),         |
|     |       |           |            |      | gemfibrozil (Lopid) |
|     |       |           |            |      | (Gemcor),           |
|     |       |           |            |      | fenofibrate         |
|     |       |           |            |      | (Tricor) (Lofibra)  |
|     |       |           |            |      |                     |
|     |       |           |            |      | **Omega- Fatty      |
|     |       |           |            |      | Acids (Fish         |
|     |       |           |            |      | Oils):**            |
|     |       |           |            |      | Marine-derived      |
|     |       |           |            |      | omega-3 fatty acid  |
|     |       |           |            |      | supplements         |
|     |       |           |            |      | (DHA/EPA)           |
+-----+-------+-----------+------------+------+---------------------+

+----+------+----------+----------+----+-----------------------------+
| *  | **   | **Descr  | *        | ** | **Definition**              |
| *P | Asse | iption** | *Codes** | Re |                             |
| at | ssme |          |          | su |                             |
| ie | nt** |          |          | lt |                             |
| nt |      |          |          | ** |                             |
| ID | **Va |          |          |    |                             |
| ** | riab |          |          |    |                             |
|    | le** |          |          |    |                             |
+----+------+----------+----------+----+-----------------------------+
|    | **L  | Was a    | 1.  Yes  |    | **[Lipid-lowering           |
|    | IPAT | lipid-   |          |    | Medications]{.underline}**  |
|    | DC** | lowering | 2.  No   |    |                             |
|    |      | me       |          |    | **HMG-CoA Reductase         |
|    |      | dication |          |    | Inhibitors (Statins):**     |
|    |      | pr       |          |    | fluvastatin sodium          |
|    |      | escribed |          |    | (Lescol), atorvastatin      |
|    |      |          |          |    | calcium (Lipitor),          |
|    |      | at       |          |    | lovastatin (Mevacor)        |
|    |      | di       |          |    | (Altocor), pravastatin      |
|    |      | scharge? |          |    | sodium (Pravacol),          |
|    |      |          |          |    | simvastatin (Zocor),        |
|    |      |          |          |    | rosuvastatin calcium        |
|    |      |          |          |    | (Crestor)                   |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Cholesterol absorption    |
|    |      |          |          |    | inhibitors**: ezetimibe     |
|    |      |          |          |    | (Zetia)                     |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Combination**:            |
|    |      |          |          |    | ezetimibe/simvastatin       |
|    |      |          |          |    | (Vytorin),                  |
|    |      |          |          |    | Niaspan/lovastatin          |
|    |      |          |          |    | (Advicor)                   |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Nicotinic Acid:** niacin  |
|    |      |          |          |    | extended release tablets    |
|    |      |          |          |    | (Niaspan), Crystalline      |
|    |      |          |          |    | niacin, sustained or timed  |
|    |      |          |          |    | release niacin              |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Bile Acid                 |
|    |      |          |          |    | Se                          |
|    |      |          |          |    | questrants**[:]{.underline} |
|    |      |          |          |    | colestipol hydrochloride    |
|    |      |          |          |    | (Colestid), colesevelam     |
|    |      |          |          |    | hydrochloride (Welchol),    |
|    |      |          |          |    | cholestyramine (Questran)   |
|    |      |          |          |    | (Locholest)                 |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Fibrates**: clofibrate    |
|    |      |          |          |    | (Atromid-S) (Abitrate),     |
|    |      |          |          |    | gemfibrozil (Lopid)         |
|    |      |          |          |    | (Gemcor), fenofibrate       |
|    |      |          |          |    | (Tricor) (Lofibra)          |
|    |      |          |          |    |                             |
|    |      |          |          |    | **Omega- Fatty Acids (Fish  |
|    |      |          |          |    | Oils):** Marine-derived     |
|    |      |          |          |    | omega-3 fatty acid          |
|    |      |          |          |    | supplements (DHA/EPA)       |
+----+------+----------+----------+----+-----------------------------+
|    | **NO | Does the | 1.  1\.  |    | **Notes:**                  |
|    | LIPW | record   |          |    |                             |
|    | HY** | document |   Lipid- |    | -   Documentation of an     |
|    |      | any of   | lowering |    |     allergy/sensitivity to  |
|    |      | the      |          |    |     one particular          |
|    |      | f        | 2.  me   |    |     lipid-lowering          |
|    |      | ollowing | dication |    |     medication is           |
|    |      | c        |          |    |     acceptable to take as   |
|    |      | ontraind |  allergy |    |     an allergy to the       |
|    |      | ications |          |    |     entire class of         |
|    |      | /reasons | 2\.      |    |     lipid-lowering          |
|    |      | for not  | Other    |    |     medications (e.g.,      |
|    |      | pre      | reason   |    |     "allergic to            |
|    |      | scribing |          |    |     atorvastatin").         |
|    |      | a        | do       |    |                             |
|    |      | lipid-   | cumented |    | -   Reasons for not         |
|    |      | lowering | by a     |    |     prescribing a           |
|    |      | me       |          |    |     lipid-lowering          |
|    |      | dication | physicia |    |     medication at discharge |
|    |      | at       | n/APN/PA |    |     must be explicitly      |
|    |      | di       | for      |    |     documented (e.g.,       |
|    |      | scharge? |          |    |     "Active PUD. Lipid      |
|    |      |          | not      |    |     lowering therapy        |
|    |      |          | pre      |    |     contraindicated.") or   |
|    |      |          | scribing |    |     clearly implied (e.g.,  |
|    |      |          | a lipid- |    |     "Hx of muscle soreness  |
|    |      |          |          |    |     to statins in the       |
|    |      |          | lowering |    |     past.")                 |
|    |      |          | me       |    |                             |
|    |      |          | dication |    |                             |
|    |      |          | at       |    |                             |
|    |      |          |          |    |                             |
|    |      |          | di       |    |                             |
|    |      |          | scharge. |    |                             |
+----+------+----------+----------+----+-----------------------------+