Venous Thromboembolism Prophylaxis
Compare Versions of: "Venous Thromboembolism Prophylaxis"
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period |
|---|---|---|---|
| Title | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis |
| CMS eCQM ID | CMS108v11 | CMS108v12 | CMS108v13 |
| Short Name |
VTE-1 |
VTE-1 |
VTE-1 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable |
| Measure Steward | The Joint Commission | The Joint Commission | The Joint Commission |
| Description |
This 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 |
This 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 |
This 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 |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process |
| Stratification | *See CMS108v11.html |
None |
None |
| Risk Adjustment | *See CMS108v11.html |
None |
None |
| Rationale | *See CMS108v11.html |
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). |
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). |
| Clinical Recommendation Statement | *See CMS108v11.html |
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. |
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. |
| Improvement Notation |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
| Definition | *See CMS108v11.html |
None |
None |
| Guidance |
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. |
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. |
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. |
| Initial Population |
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 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 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 |
| Denominator |
Initial population |
Equals Initial population |
Equals Initial population |
| Denominator Exclusions |
* 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 start the day of or the day after hospital admission |
- 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 |
- 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 |
| Numerator |
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) |
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) |
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) |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
| Next Version | No Version Available | ||
| Previous Version | No Version Available |
Additional Resources for CMS108v11
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated rationale with more current evidence.
Measure Section: Rationale
Source of Change: Measure Lead
Updated references.
Measure Section: Reference
Source of Change: Standards/Technical Update
Changed 'VTE Prophylaxis' to 'VTE prophylaxis' to align with typographical standard.
Measure Section: Guidance
Source of Change: Measure Lead
Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the denominator population.
Measure Section: Guidance
Source of Change: Measure Lead
Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
Revised the denominator exclusions narrative to list exclusions in the same order as the logic for improved readability.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Standardized use of parentheses in numerator statement.
Measure Section: Numerator
Source of Change: Measure Lead
Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
Replaced reference to Global.ToDate with identical function named TJC.TruncateTime because Global.ToDate was retired.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Replaced 'Device, Applied' with 'Procedure, Performed' datatype to align with QDM v5.6 updates and created 3 new value sets with SNOMED CT codes to align with terminology recommendations by QDM datatype.
Measure Section: Numerator
Source of Change: Standards/Technical Update
Updated definition name to align with logic content.
Measure Section: Numerator
Source of Change: Measure Lead
Replaced age calculation from BirthDate with CQL function AgeInYearsAt in the TJCOverall and VTE libraries.
Measure Section: Definitions
Source of Change: Measure Lead
Replaced Global.ToDate() with TJC.TruncateTime() in the function of FromDayOfStartOfHospitalizationToDayAfterAdmission and FromDayOfStartOfHospitalizationToDayAfterFirstICU.
Measure Section: Functions
Source of Change: Measure Lead
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the timing precision in definitions using the functions TJC.'CalendarDayOfOrDayAfter' and VTE.'FromDayOfStartOfHospitalizationToDayAfterFirstICU' from datetime to date by adding 'day of' to align with the measure intent.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Updated the version number of the TJC Overall Library to v6.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated the version number of the VTE Library to v6.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Updated definition names to reflect the removal of the 'Device, Applied' datatype.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Changed 'With' to 'with' in the definition names to align with CQL Style Guide.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
Value set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Value set Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272): Deleted 3 SNOMED CT codes (289754003, 290691008, 89528006) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Deleted 5 RxNorm codes (1114198, 1232082, 1232086, 1549682, 2059015) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Deleted 5 SNOMED CT codes (200237000, 200238005, 280966008, 63795001, 84216001) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Deleted 62 SNOMED CT codes based on terminology update. Deleted 50 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Deleted 1 SNOMED CT code (397956004) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Graduated compression stockings (GCS) (2.16.840.1.113883.3.117.1.7.1.256): Deleted 12 SNOMED CT codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Added value set Application of Venous Foot Pumps (VFP) (2.16.840.1.113762.1.4.1110.64) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Annual Update
Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMED CT code (397745006) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50): Added 1 RxNorm code (2588062) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 3 ICD-10-CM codes (F32.A, T40.712A, T40.722A) based on terminology update. Deleted 1 ICD-10-CM code (T40.7X2A) based on terminology update. Deleted 4 SNOMED CT codes (162722001, 3503000, 391099000, 50878001) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Added value set Application of Intermittent Pneumatic Compression Devices (IPC) (2.16.840.1.113762.1.4.1110.65) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Annual Update
Added value set Application of Graduated Compression Stockings (GCS) (2.16.840.1.113762.1.4.1110.66) based on change in measure requirements/measure specification.
Measure Section: Terminology
Source of Change: Annual Update
Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Deleted 2 SNOMED CT codes (195394007, 266267005) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Deleted 2 SNOMED CT codes (238212008, 28933001) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead