Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

Last updated: May 4, 2017

CMS Measure ID: CMS73v4
Version: 4
NQF Number: 0373
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.

Initial Patient Population:

Patients with a diagnosis code for venous thromboembolism (VTE), a patient age greater than or equal to 18 years, and a length of stay less than or equal to 120 days.

Denominator Statement:

Patients with confirmed VTE who received warfarin.

Denominator Exclusions:
  • Patients with Comfort Measures documented
  • Patients discharged to a health care facility for hospice care
  • Patients discharged to home for hospice care
  • Patients who expired
  • Patients who left against medical advice
  • Patients discharged to another hospital
  • Patients without warfarin therapy during hospitalization
  • Patients without VTE confirmed by diagnostic testing
Numerator Statement:

Patients who received overlap therapy (warfarin and parenteral anticoagulation):

  • Five or more days, with an INR greater than or equal to 2 prior to discontinuation of parenteral therapy OR
  • Five or more days, with an INR less than 2 and discharged on overlap therapy OR
  • Less than five days and discharged on overlap therapy OR
  • With documentation of reason for discontinuation of parenteral therapy OR
  • With documentation of a reason for no overlap therapy
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: VTE3
Next Version: Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
Previous Version: Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in the rate

Guidance:

CMS recognizes the difficulty in capturing the VTE confirmed concept required in this measure and suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs consider selecting alternative electronic clinical quality measures (eCQMs) to meet program requirements for meaningful use. If suitable alternatives are unavailable, CMS will accept a 0 denominator submission for the eCQM version only for this measure.

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Specifications

Release Notes

Header

  • Added guidance statement from CMS regarding the capture of the VTE confirmed concept and its impact on the use of the measure.
  • Copyright updated.
  • eMeasure version number incremented.
  • Removed guidance statement related to date difference function calculations, as this logic was refactored and the date difference function is no longer used in the logic.
  • Updated references in header.

Logic

  • Added the administration of the oral direct thrombin inhibitor dabigatran to the Numerator logic, as the administration of these medications could justify the absence or discontinuation of overlap therapy.
  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the 'Intersection of' operator to specify the selection of the data sets common to all individual statements underneath the 'Intersection of'.
  • Introduced variables $EncounterInpatient, $DiagnosisVTE, $InterventionComfortMeasures, $MedicationReasonForNotAdministeringParenteralAnticoagulantDose, $MedicationReasonForNoParenteralAnticoagulant, $MedicationWarfarinParenteralAnticoagulantOverlap, and $MedicationReasonForNoParenteralAnticoagulantAtDischarge to allow re-use of logical expressions and reduce redundancy/complexity.
  • Removed Date Difference function from Numerator logic and replaced it with the expression of logic in the Numerator, -The line of logic 'AND: Difference between dates >= 4 days of:” has been removed and replaced with the timing relationship '>=4 day(s) starts before start of”. The 'First” segment of logic is now the left-hand side of this clause, and the 'Most Recent” segment of logic is now the right-hand side of this clause. -The line of logic 'AND: Difference between dates < 4 days of:” has been removed and replaced with the timing relationship '< 4 day(s) starts before start of”. The 'First” segment of logic is now the left-hand side of this clause, and the 'Most Recent” segment of logic is now the right-hand side of this clause.
  • Removed occurrencing and added timing constraint to 'Encounter, Performed: Emergency Department Visit' when this QDM element is used on the right-hand side of a temporal operation, to enforce a constraint that wasn't necessarily achieved through occurrencing alone.
  • Removed unnecessary 'First' from the 'Occurrence A of Diagnostic Study, Performed: VTE Diagnostic Test' in the Denominator logic to reduce complexity and align with other VTE measures.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Revised Numerator logic criteria relating warfarin and parenteral anticoagulant administration on the same day to clarify which medication datetime should be used in determining the 'First' and 'Most Recent' administrations.
  • Revised Numerator logic to ensure logic consistency in reference to the most recent parenteral anticoagulant administered during the hospitalization (either in the ED or in the Inpatient Encounter).
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.
  • Under the overlap therapy duration >= 4 days Numerator logic block, removed unnecessary reference to parenteral administration in the ED as a possibility for the most recent occurrence of the parenteral anticoagulant administration. If a patient is on overlap therapy >= 4 days, it would be impossible for the last parenteral anticoagulant administration to occur in the ED.
  • Updated logic for applying 'AND' logical operator in the left-hand side or right-hand side of a timing clause.

Value Sets

  • Value set Discharge to Acute Care Facility (OID 2.16.840.1.113883.3.117.1.7.1.87): Deleted 1 SNOMED code (306699001) and added 2 SNOMED codes (306703003, 434781000124105). Updated value set name from Discharge to Another Hospital to Discharge to Acute Care Facility.
  • Value set Obstetrics VTE (OID 2.16.840.1.113883.3.117.1.7.1.264): Added 8 ICD10CM codes (O03.35, O07.35, O22.8X1, O22.8X2, O22.8X3, O22.8X9, O87.0, O87.3) and 1 SNOMED code (609497003).
  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (OID 2.16.840.1.113883.3.117.1.7.1.134): Updated vale set name from Oral Factor Xa Inhibitor for VTE Prophylaxis to Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment.
  • Value set Parenteral Anticoagulant (OID 2.16.840.1.113883.3.117.1.7.1.266): Deleted 3 RXNORM codes (1037045, 1037179, 1362060) and added 3 RXNORM codes (1361226, 1362831, 308769).
  • Value set Parenteral anticoagulant ingredient specific (OID 2.16.840.1.113762.1.4.1021.4): Deleted 1 RXNORM code (1037042) and added 1 RXNORM code (60819).
  • Value set Venous Thromboembolism (OID 2.16.840.1.113883.3.117.1.7.1.279): Deleted 5 ICD10CM codes (I80.231, I80.232, I80.233, I80.239, I82.210) and 12 SNOMED codes. Added 4 SNOMED codes (1001000119102, 132251000119101, 132251000119106, 132251000119107).
  • Value set VTE Confirmed (OID 2.16.840.1.113883.3.117.1.7.1.407): Deleted 37 SNOMED codes; added 5 SNOMED codes (1001000119102, 132251000119101, 132251000119106, 132301000119107, 57834008).

External Resources