Venous Thromboembolism Prophylaxis
Compare Versions of: "Venous Thromboembolism Prophylaxis"
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| Measure Information | 2022 Reporting Period | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period |
|---|---|---|---|---|
| Title | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis |
| CMS eCQM ID | CMS108v10 | CMS108v11 | CMS108v12 | CMS108v13 |
| Short Name |
VTE-1 |
VTE-1 |
VTE-1 |
VTE-1 |
| CBE ID* | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
| Measure Steward | The Joint Commission | The Joint Commission | The Joint Commission | The Joint Commission |
| Description |
This measure assesses the number of patients who received 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 |
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 | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS108v10.html | *See CMS108v11.html |
None |
None |
| Risk Adjustment | *See CMS108v10.html | *See CMS108v11.html |
None |
None |
| Rationale | *See CMS108v10.html | *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 CMS108v10.html | *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 |
Improvement noted as an increase in rate |
| Definition | *See CMS108v10.html | *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." 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 5.5. Please refer to the eCQI resource center 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. |
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 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 |
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 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 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 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) |
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 |
Not Applicable |
| Denominator Exceptions |
None |
None |
None |
None |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS108v12
Header
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
Updated references.
Measure Section: Reference
Source of Change: Measure Lead
Updated exclusion language in the narrative to align with measure intent and current CQL timing requirements.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section: Multiple Sections
Source of Change: Annual Update
Logic
Consolidated and simplified the initial population definitions to improve clarity and efficiency.
Measure Section: Initial Population
Source of Change: Measure Lead
Changed the alias names from 'NoVTEDevice' to 'NoMechanicalProphylaxis' because the definition was renamed because the QDM data element associated with the name is no longer a valid QDM data element.
Measure Section: Numerator
Source of Change: Standards/Technical Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section: Definitions
Source of Change: Standards/Technical Update
Updated the version number of the TJC Overall Library to v7.1.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the version number of the VTE Library to v7.2.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the version number of the TJC Overall Library to v7.1.000.
Measure Section: Functions
Source of Change: Annual Update
Updated the version number of the VTE Library to v7.2.000.
Measure Section: Functions
Source of Change: Annual 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 Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202): Added 2 SNOMED CT codes (312442005, 428076002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Added 6 RxNorm codes (2590616, 2590620, 2590623, 2590627, 2590631, 2590635) 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 4 SNOMED CT codes (119884008, 235288004, 238215005, 315323003) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Glycoprotein IIb IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41): Deleted 1 RxNorm code (241162) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Added 7 ICD-10-PCS codes (0UT90ZL, 0UT97ZL, 0UT98ZL, 0U508ZZ, 0U518ZZ, 0U528ZZ, 0U548ZZ) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 8 ICD-10-PCS codes (0SR9069, 0SR906A, 0SR906Z, 0SR90EZ, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB0EZ) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Intermittent pneumatic compression devices (2.16.840.1.113883.3.117.1.7.1.214): Added 1 SNOMED CT code (432441000124100) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Added 1 SNOMED CT code (1201979001) based on terminology update. Deleted 3 SNOMED CT codes (171446006, 244238001, 82443007) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Added 20 ICD-10-PCS codes based on terminology update.
Measure Section: Terminology
Source of Change: ONC Project Tracking System (JIRA): CQM-5903
Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Added 1 RxNorm code (2618839) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.117.1.7.1.473): Renamed to Medical Reason For Not Providing Treatment based on recommended value set naming conventions.
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 18 SNOMED CT codes based on terminology update. Deleted 18 SNOMED CT codes based on terminology update. Added 36 ICD-10-CM codes based on terminology update. Deleted 2 ICD-10-CM codes (F03.91, F43.8) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set (2.16.840.1.113883.3.117.1.7.1.263): Renamed to Obstetrical or Pregnancy Related Conditions based on recommended value set naming conventions.
Measure Section: Terminology
Source of Change: Annual Update
Value set Obstetrical or Pregnancy Related Conditions (2.16.840.1.113883.3.117.1.7.1.263): Added 21 SNOMED CT codes based on terminology update. Deleted 44 SNOMED CT codes based on terminology update. Added 177 ICD-10-CM codes based on terminology update. Deleted 14 ICD-10-CM codes based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Obstetrics VTE (2.16.840.1.113883.3.117.1.7.1.264): Added 3 SNOMED CT codes (609449004, 609459003, 609480009) based on terminology update. Deleted 6 SNOMED CT codes (51096002, 57734001, 21604008, 26743002, 37787009, 55589000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 2 SNOMED CT codes (1162745003, 895451009) based on terminology update. Deleted 5 SNOMED CT codes (183944003, 413312003, 183947005, 371138003, 609589008) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead