2024 Reporting PeriodCMS108v12VTE-1

]]>Not ApplicableThis measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

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None

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Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

]]>

Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

]]>

Not Applicable

]]>

Equals Initial population

]]>

- Inpatient hospitalizations for patients who have a length of stay less than 2 days

- Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day

- Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke

- Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries

- Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission

- Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that end the day of or the day after hospital admission

]]>

None

]]>The Joint Commission]]>Proportion]]>Process]]>

Improvement noted as an increase in rate

]]>When low dose unfractionated heparin is administered for VTE prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), ranges from 350,000 to 600,000 (Maynard, 2016). According to the Centers for Disease Control and Prevention (CDC) 2020 statistics, 1-2 per 1,000 adults in the United States are clinically diagnosed with VTE each year. Increased incidence is reported in the elderly (1 per 100) compared to young adults (1 per 10,000) (Henke et al., 2020).

VTE is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Hospitalized patients at high-risk for VTE may develop an asymptomatic DVT, and die from PE even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts et al., 2008).

American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. (NOTE: Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.)

Despite its proven effectiveness, VTE prophylaxis remains underused or inappropriately used in both medical and surgical patients (Kahn et al., 2018). The ENDORSE study evaluated prophylaxis rates in 17,084 major surgery patients and found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis with various rates reported for different types of surgery (Cohen et al., 2008). More recently, a systemic review of multiple randomized controlled trials found that system-wide interventions, such as computer alerts to physicians and other healthcare professionals, increased the use of appropriate VTE prophylaxis while reducing the number of symptomatic VTE at three months (Kahn et al., 2018).

]]>

None

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None

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Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.

]]>2025 Reporting PeriodCMS108v13VTE-1

]]>Not ApplicableThis measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

]]>None

]]>Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics that ends during the measurement period

]]>Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

]]>Not Applicable

]]>Equals Initial population

]]>- Inpatient hospitalizations for patients who have a length of stay less than 2 days

- Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day

- Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke

- Inpatient hospitalizations for patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries

- Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission

- Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that end the day of or the day after hospital admission

]]>None

]]>The Joint Commission]]>Proportion]]>Process]]>Improvement noted as an increase in rate

]]>When low dose unfractionated heparin is administered for VTE prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), ranges from 350,000 to 600,000 (Maynard, 2016). According to the Centers for Disease Control and Prevention (CDC) 2020 statistics, 1-2 per 1,000 adults in the United States are clinically diagnosed with VTE each year (CDC, 2020). Increased incidence is reported in the elderly (1 per 100) compared to young adults (1 per 10,000) (Henke et al., 2020).

VTE is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Hospitalized patients at high-risk for VTE may develop an asymptomatic DVT, and die from PE even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts et al., 2008).

American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. (NOTE: Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.)

Despite its proven effectiveness, VTE prophylaxis remains underused or inappropriately used in both medical and surgical patients (Kahn et al., 2018). The ENDORSE study evaluated prophylaxis rates in 17,084 major surgery patients and found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis with various rates reported for different types of surgery (Cohen et al., 2008). More recently, a systemic review of multiple randomized controlled trials found that system-wide interventions, such as computer alerts to physicians and other healthcare professionals, increased the use of appropriate VTE prophylaxis while reducing the number of symptomatic VTE at three months (Kahn et al., 2018).

]]>None

]]>None

]]>Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.

]]>2026 Reporting PeriodCMS108v14VTE-1

]]>Not ApplicableThis measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that end the day after hospital admission

]]>None

]]>Inpatient hospitalizations for patients age 18 and older, discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics that ends during the measurement period

]]>Inpatient hospitalizations for patients who received VTE prophylaxis:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day after hospital admission)

Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given:

- between the day of arrival and the day after hospital admission

- the day of or the day after surgery end date (for surgeries that end the day after hospital admission)

]]>None

]]>Equals Initial Population

]]>- Inpatient hospitalizations for patients who have a length of stay less than 2 days

- Inpatient hospitalizations for patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day

- Inpatient hospitalizations for patients with a principal diagnosis of mental disorders or stroke

- Inpatient hospitalizations for patients with a principal procedure of selected surgeries

- Inpatient hospitalizations for patients with comfort measures documented anytime between the day of arrival and the day after hospital admission - Inpatient hospitalizations for patients with comfort measures documented by the day after surgery end date for surgeries that end the day after hospital admission

]]>None

]]>The Joint Commission]]>Proportion]]>Process]]>Increased score indicates improvement

]]>When low dose unfractionated heparin is administered for VTE prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the medical doctor, advanced practice registered nurse, physician assistant, or pharmacist and linked with VTE prophylaxis. The only exception is patient refusal may be documented by a nurse. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."This measure does not require the use of a specific risk assessment model or tool (e.g., Caprini, Padua, and IMPROVE) to determine VTE risk.The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. Inpatient hospitalizations for patients with a principal procedure of selected surgeries are excluded from the measure’s denominator. Selected surgeries include general surgery, gynecological surgery, hip fracture surgery, hip/knee replacement surgery, intracranial neurosurgery, and urological surgery.Inpatient hospitalizations for patients administered apixaban or edoxaban, medications included in the “Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment” value set, would be counted in the numerator population only when the patients also have either a prior or present diagnosis of atrial fibrillation, a prior diagnosis of VTE, or a prior or present procedure of hip/knee replacement surgery.This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), ranges from 350,000 to 600,000 (Maynard, 2016). According to the Centers for Disease Control and Prevention (CDC) 2020 statistics, 1-2 per 1,000 adults in the United States are clinically diagnosed with VTE each year (CDC, 2020). Increased incidence is reported in the elderly (1 per 100) compared to young adults (1 per 10,000) (Henke et al., 2020).

VTE is a known complication of hospitalization, frequently extending the length of stay and increasing hospital mortality (Maynard, 2016). Approximately 20% of VTE are associated with a surgical procedure (Henke et al., 2020). Hospitalized patients at high-risk for VTE may develop an asymptomatic DVT, and die from PE even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts et al., 2008).

American Society of Hematology (ASH) 2018 VTE prophylaxis guidelines strongly recommend pharmacological prophylaxis using unfractionated heparin (UFH), low molecular weight heparin (LMWH) or fondaparinux for acutely and critically ill hospitalized medical patients, unless contraindicated. The use of mechanical prophylaxis is an acceptable alternative for patients with increased risk of bleeding and preferred over no prophylaxis. ASH 2019 guidelines for surgical patients similarly recommend pharmacological or mechanical prophylaxis over no VTE prophylaxis. (NOTE: Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.)

Despite its proven effectiveness, VTE prophylaxis remains underused or inappropriately used in both medical and surgical patients (Kahn et al., 2018). The ENDORSE study evaluated prophylaxis rates in 17,084 major surgery patients and found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis with various rates reported for different types of surgery (Cohen et al., 2008). More recently, a systemic review of multiple randomized controlled trials found that system-wide interventions, such as computer alerts to physicians and other healthcare professionals, increased the use of appropriate VTE prophylaxis while reducing the number of symptomatic VTE at three months (Kahn et al., 2018).

]]>None

]]>None

]]>Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary embolism. Screening all patients is the only evidence-based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis and given appropriate prophylaxis when indicated.

]]>