They also could require other measures. Identifying Best Practices to Improve In-Hospital Stroke Management Stroke Corner - Education - neuropt.org Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 7 cases are sampled. hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. The following table identifies the population . Return to Clinical Data Processing Flow in the Data Processing section. MjMO2n7( LBm6N.Hl#|oKP?lEF@L9ew,w\XpP{]8vxmtV}Or,kU{ `B7{"'Tf(DL[}ZEY 7'XoFo(|{%Jlv,_v}%DPnpoAucQGPy'YVJGXv:E j5(kts,?BcBKd?R . ASR-OP-2b Hemorrhagic Stroke3. Disclaimer of Warranties and Liabilities. In the final section, I review the way this information is submitted to The Joint Commission and CMS. STK-8 Stroke Education18. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . Below are the list of Stroke measures by Certification Program. ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. PDF Stroke Core Performance Measures HOS-Sanford Medical Center Fargo PDF Hospital Outpatient Quality Reporting Stroke Measure Set - RWHC x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) Stroke is a leading cause of serious, long-term disability in the United States. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. STK-2 Discharged on Antithrombotic Therapy13. The next measure set we review is abbreviated ASR-IP/OP. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. You can use the words "AND" and "OR" along . Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. CSTK-09a Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who are transferred from another hospital and undergo endovascular treatment2. This content does not have an Arabic version. The six measures are: . Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. What is wrong with these people making it so complicated for us? Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 1-800-AHA-USA-1 All rights reserved. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ 2021; 96:e1812-e1822 . STK-OP-1b Hemorrhagic Strok3. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 78 cases for the quarter (20% of 392 equals 78.4 rounded to the next highest whole number equals 78). The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. You can decide how often to receive updates. STK-1 Venous Thromboembolism (VTE Prophylaxis)4. 3 0 obj STK-5 Antithrombotic Therapy By End of Hospital Day Two8. This consensus core set was further discussed by all Collaborative members before being finalized. <> STK-1 Venous Thromboembolism (VTE Prophylaxis)12. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. CPT only copyright 2019 American Medical Association. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! A hospitals Ischemic sub-population is 5 patients during February. Numerous published studies demonstrate the program's success in improving patient outcomes. The American Medical Association reserves all rights to approve any license with any Federal agency. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 20% of this subpopulation or 25 cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25). The Ischemic sub-population has 392 patients per quarter, which requires a 20% sample size, or 79 cases (twenty percent of 392 equals 78.4 rounded to the next highest whole number equals 79). >ob=AOtVt. Initial Population: Inpatient hospitalizations for patients age 18 and older . Get With The Guidelines - Stroke Overview - American Heart Association Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the (AMA is not recommending their use. 4 0 obj A hospitals Hemorrhagic sub-population is 316 during February. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). Learn how working with the Joint Commission benefits your organization and community. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). endstream endobj startxref CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. Measure Type: OutpatientNumber of Measures Included: There are five process measures (youll see one additional measure listed below that is not reported and one additional measure that is retired starting with July 1, 2021 discharges). Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. Set the Initial Patient Population Reject Case Flag to equal No. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Comprehensive Stroke Arrival Time to Skin Puncture, Comprehensive Stroke Post Thrombolysis Revascularization Rate, Comprehensive Stroke Timeliness of IV Thrombolytic Therapy, Advertising and sponsorship opportunities, Percent of ischemic and hemorrhagic stroke patients who received venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission. Start STK Initial Patient Population logic sub-routine. All rights reserved. . Set the Initial Patient Population Reject Case Flag to equal Yes. STK-2 Discharged on Antithrombotic Therapy8. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . The AMA is a third party beneficiary to this Agreement. . For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). The required monthly sample is 60 cases. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. *Note: There are additional measures needed to fulfill this certification. A hospitals ischemic stroke patient population size is 295 cases during March. PDF Core Measures: The Nurse's Role - r N May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). An antithrombotic agent is a drug that reduces the formation of blood clots. Specifications Manual for Joint Commission National Quality Measures (v2021B), Stroke (STK) Initial Patient Population Algorithm Narrative, Anticoagulation Therapy Prescribed at Discharge, Antithrombotic Therapy Administered by End of Hospital Day 2, Antithrombotic Therapy Prescribed at Discharge, Education Addresses Activation of Emergency Medical System, Education Addresses Follow-up After Discharge, Education Addresses Medication Prescribed at Discharge, Education Addresses Risk Factors for Stroke, Education Addresses Warning Signs and Symptoms of Stroke, IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival, Reason for Extending the Initiation of IV Alteplase, Reason for No VTE Prophylaxis Hospital Admission, Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2, Reason for Not Prescribing Statin Medication at Discharge, Statin Medication Prescribed at Discharge, Appendix E - Overview of Measure Information Form and Flowchart Formats, Cover Page for the Joint Commission Manual, Joint Commission Clinical Data Processing Flow, Joint Commission National Quality Measures Data Processing, Using the The Joint Commission's National Measure Specifications Manual, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two, All Records, Not collected for HBIPS-2 and HBIPS-3, All Records, Optional for HBIPS-2, HBIPS-3, All Records, Optional for All HBIPS Records. decreased providers collection burden and cost. So, Ive attempted to structure it in a way that will be a reference for you. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. The Perfect Care Report identifies patients that received perfect care. >0SPJ*@6W/rq+ERY_X&14>k( 1-800-242-8721 The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. STK-8 Stroke Education10. A hospitals Ischemic sub-population is 316 during January. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. Medisolv can help you along the way. CSTK-09 Arrival Time to Skin Puncture, 1. National Center CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. If the Length of Stay is less than or equal to 120 days, continue processing and proceed to ICD-10-CM Principal Diagnosis Code Check. The psychometric properties of the measures are reviewed using a modified EDGE (Evidence Database to Guide Effectiveness) template (a format recommended by the APTA EDGE task force). IQR Measures - Centers for Medicare & Medicaid Services Data collection for STK-OP-1 will replace ASR-OP-2. %%EOF All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. . Here I have broken it into the inpatient measure set and the outpatient measure set. STK-OP-1 Door to Transfer to Another Hospital, 1. 2021; 97: . Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Core Rulebook (disambiguation) This is a disambiguation page; that is, one that points to other pages that might otherwise have the same name.Pathfinder 2E.Expand your capabilities by selecting general feats that improve your statistics or give you. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the (AMA is not recommending their use. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 28 cases for the month. 2018 - 2021. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. ASR-OP-2c Ischemic Stroke; drip and ship4. Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. Hospital Outpatient Quality Measure Stroke. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. lock 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream Assemble your multidisciplinary team to determine roles and processes for entering patient data. or CSTK-09 Arrival Time to Skin Puncture, 8. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. STK-2 Discharged on Antithrombotic Therapy5. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. Please see link below for more information. R,A`=N T$gZq,AW@0H#`.K#AJk_~}~Dc7?o=0T,qp{"+&y8N^-9yG-W +~ZY(DA[xvc2EGJv;P.Q12`3'o0f}ahq+ci;")i EmNW`0}d\K?QD-ki'e1ACa%i^\|.I$a-4>b(L These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. 0 In addition, TJC established the Certification Measure Information Process (CMIP) tool where hospitals must manually enter their certification data for the program certifications we reviewed above (ASR, PSC, TSC and CSC). ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received means youve safely connected to the .gov website. ASR-IP-3: Discharged on Antithrombotic Therapy4. This means the patient passed every measure they qualified for. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. See our editorial policies and staff. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. PDF Hospital OQR Quality Measures and Timelines for CY 2021 Payment 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Reports, http://www.qualityforum.org/CQMC_Core_Sets.aspx. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time 2023 American Heart Association, Inc. All rights reserved. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. Diesel Fuel Injector - 2004.5-2007 Ford 6.0L Power Stroke The change in the performance measure requirements for Acute Stroke Ready Hospitals, (i.e., STK-OP-1 replacing ASR-OP-2 effective with discharges on and after July 1, 2021) can be found in several places. Each measure includes patients from one or more categories. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. Test your ideas. <> The Measure Steward refers to the organization that is responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Written by American Heart Association editorial staff and reviewed by science and medicine advisers. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! CSTK-02 Modified Rankin Score (mRS at 90 Days)3. website belongs to an official government organization in the United States. The final clinical diagnosis is used to identify the measure population. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. CPT is a registered trademark of the American Medical Association. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). This is increasingly important as the health care system moves towards value-based reimbursement models. The core measurescan be found at: http://www.qualityforum.org/cqmc/. with acute ischemic stroke in the hospital setting will submit this measure. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. Patients admitted to the hospital for inpatient acute care are included in the CSTK 3-Hemorrhagic Stroke subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.2, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. Find the exact resources you need to succeed in your accreditation journey. A hospitals Hemorrhagic sub-population is 3 patients during January. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. Download Get With The Guidelines- Stroke fact sheets and forms here. endobj STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Return to Clinical Data Processing Flow in the Data Processing section. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . Recommended Core Measures | CMS Measure Type: InpatientNumber of Measures Included: 8Certification Requirement: The Joint Commissions Primary Stroke Certification, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two. If the Length of Stay is greater than 120 days, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Brainstorm with your team to find ways to improve your hospital's treatment rates. Heres how you know. Centers for Medicare and Medicaid Services Measures Inventory Tool By not making a selection you will be agreeing to the use of our cookies. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Using the quarterly sampling table for the Ischemic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). stream <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> STK-8 Stroke Education13. Core Measures | CMS - Centers for Medicare & Medicaid Services Learn about the priorities that drive us and how we are helping propel health care forward. To address this problem, the Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Remember that changes do not have to be large. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Refine processes and protocols to ensure they are in line with the guidelines. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9.