Venous Thromboembolism Prophylaxis
Compare Versions of: "Venous Thromboembolism Prophylaxis"
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period | 2026 Reporting Period |
|---|---|---|---|---|
| Title | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis | Venous Thromboembolism Prophylaxis |
| CMS eCQM ID | CMS108v11 | CMS108v12 | CMS108v13 | CMS108v14 |
| 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 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 Show more >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 Show less |
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 Show more >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 Show less |
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 Show more >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 Show less |
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 end the day after hospital... admission Show more >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 end the day after hospital admission Show less |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Process | Process | Process | Process |
| Stratification | *See CMS108v11.html |
None |
None |
None |
| Risk Adjustment | *See CMS108v11.html |
None |
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). Show more >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). Show less |
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). Show more >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). Show less |
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). Show more >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). Show less |
| 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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
| Improvement Notation |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
Improvement noted as an increase in rate |
Increased score indicates improvement |
| Definition | *See CMS108v11.html |
None |
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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
| 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 |
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 |
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 Show more >* 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 Show less |
- 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 Show more >- 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 Show less |
- 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 Show more >- 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 Show less |
- 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 Show more >- 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 Show less |
| 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) Show more >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) Show less |
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) Show more >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) Show less |
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) Show more >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) Show less |
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) Show more >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) Show less |
| Numerator Exclusions |
Not Applicable |
Not Applicable |
Not Applicable |
None |
| Denominator Exceptions |
None |
None |
None |
None |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS108v14
*Note there may be more tickets for CMS108v14 in the eCQM Tracker - ASTP/ONC Project Tracking System (Jira). Only tickets tagged with their associated CMS measure ID appear.
Use the eCQM Tracker to open new issues regarding eCQM implementation. Log in required.
Header
TRN | Measure Section | Source of Change |
|---|---|---|
Updated 'eCQM Identifier (Measure Authoring Tool)' field to 'CMS ID' based on tooling update. | CMS ID | Standards/Technical Update |
Updated the eCQM version number. | eCQM Version Number | Annual Update |
Updated measurement period to reflect exact dates of reporting. | Measurement Period | Standards/Technical Update |
Updated the Description to better align with updates to the Numerator statement. | Description | Measure Lead |
Updated copyright. | Copyright | Annual Update |
Updated disclaimer. | Disclaimer | Annual Update |
Updated Improvement Notation field to read 'Increased score indicates improvement' based on tooling update to promote alignment across measures. | Improvement Notation | Standards/Technical Update |
Added new guidance clarifying when Oral Factor Xa medications are acceptable to count toward the Numerator for better alignment with logic. | Guidance | Test Case Review |
Removed reference to the 'Surgical Care Improvement Project (SCIP)' when describing selected surgery types qualifying for the Denominator Exclusions and added guidance to clarify the specific surgeries included in 'Selected Surgery' logic definition in the Guidance field. | Guidance | Measure Lead |
Added clarification that patient refusal is the only reason for no pharmacological and no mechanical VTE prophylaxis that may be documented by a nurse. | Guidance | Measure Lead |
Added guidance noting that there is not a specific risk assessment model or tool that is required to determine VTE risk for this measure. | Guidance | ONC Project Tracking System (JIRA): CQM-7034 |
Removed reference to the 'Surgical Care Improvement Project (SCIP)' when describing selected surgery types qualifying for the Denominator Exclusions and added guidance to clarify the specific surgeries included in 'Selected Surgery' logic definition in the Guidance field. | Denominator Exclusions | Measure Lead |
Updated the description of surgery timing constraints to better align with the measure intent and logic definitions. | Denominator Exclusions | Measure Lead |
Updated the description of surgery timing constraints to better align with the measure intent and logic definitions. | Numerator | Measure Lead |
Updated Numerator Exclusions field to read 'None' instead of 'Not Applicable' when no exclusions present to promote alignment across header fields. | Numerator Exclusions | Standards/Technical Update |
Updated grammar, wording, and/or formatting to improve readability and consistency. | Multiple Sections | Annual Update |
Updated references and measure header to reflect current evidence and new or updated literature. | Multiple Sections | Measure Lead |
Logic
TRN | Measure Section | Source of Change |
|---|---|---|
Updated definition names and alias for clarification and to better align with the removal of 'SCIP' in the Denominator Exclusions narrative section. | Denominator Exclusions | Measure Lead |
Updated the version number of the TJC Overall Library to v9.0.000. | Definitions | Annual Update |
Updated the version number of the VTE Library to v9.0.000. | Definitions | Annual Update |
Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'. | Definitions | Annual Update |
Updated definition names and alias for clarification and to better align with the removal of 'SCIP' in the Denominator Exclusions narrative section. | Definitions | Measure Lead |
Updated the CQL library name from 'CMS108-v13-0-000-QDM-5-6.cql' to 'CMS108VTEProphylaxis-14.2.000.cql' based on recommendation by technical experts. | Definitions | Standards/Technical Update |
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide. | Definitions | Standards/Technical Update |
Relocated the timing condition function, VTE.FromDayOfStartOfHospitalizationToDayAfterAdmission, from shared VTE Library directly to the measure logic because the function is no longer shared with VTE-2. | Functions | Measure Lead |
Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'. | Functions | Annual Update |
Updated the version number of the TJC Overall Library to v9.0.000. | Functions | Annual Update |
Updated the version number of the VTE Library to v9.0.000. | Functions | 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.
TRN | Measure Section | Source of Change |
|---|---|---|
Replaced value set used for Sex Supplemental Data Element (SDE) ONC Administrative Sex (2.16.840.1.113762.1.4.1) with value set Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121) based on updated standards. | Terminology | Standards/Technical Update |
Value set Atrial Fibrillation or Flutter (2.16.840.1.113883.3.117.1.7.1.202): Deleted 1 SNOMED CT code (195080001) based on terminology update. | Terminology | Annual Update |
Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 4 SNOMED CT codes (176006006, 36432003, 1299162005, 274026006) based on terminology update. Deleted 14 SNOMED CT codes based on terminology update. | Terminology | Annual Update |
Value set Hip Fracture Surgery (2.16.840.1.113883.3.117.1.7.1.258): Added 1 SNOMED CT code (119614000) based on terminology update. Deleted 1 SNOMED CT code (265745003) based on terminology update. Added 24 ICD-10-PCS codes based on terminology update. | Terminology | Annual Update |
Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 3 SNOMED CT codes (1290059002, 43660001, 69625007) based on terminology update. Deleted 12 SNOMED CT codes based on terminology update. | Terminology | Annual Update |
Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Added 9 SNOMED CT codes (273990004, 1287541008, 1296603004, 1296604005, 1296605006, 1296606007, 1296607003, 1296608008, 1296626006) based on terminology update. Deleted 8 SNOMED CT codes (19994000, 21205002, 243570009, 27968003, 34719005, 51991009, 79272003, 80460006) based on terminology update. | Terminology | Annual Update |
Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Deleted 2 SNOMED CT codes (179344006, 179351002) based on terminology update. | Terminology | Annual Update |
Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Added 8 SNOMED CT codes (1339031006, 128293007, 19886006, 405790001, 67698009, 763626009, 80193009, 86110000) based on terminology update. Deleted 18 SNOMED CT codes based on terminology update. Added 27 ICD-10-CM codes based on terminology update. | Terminology | Annual Update |
Value set Obstetrical or Pregnancy Related Conditions (2.16.840.1.113883.3.117.1.7.1.263): Added 9 SNOMED CT codes (10755381000119108, 1258895002, 1287713006, 156222001, 16316801000119102, 199248002, 270500004, 7870007, 95121000119108) based on terminology update. Deleted 10 SNOMED CT codes (10812081000119108, 198878009, 199205008, 199870008, 199881006, 199890004, 199901007, 200051005, 63662002, 86196005) based on terminology update. | Terminology | Annual Update |
Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 1 SNOMED CT code (1296859006) based on terminology update. Deleted 1 SNOMED CT code (105480006) based on terminology update. | Terminology | Annual Update |
Value set Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272): Added 2 SNOMED CT codes (176025009, 40173000) based on terminology update. Deleted 1 SNOMED CT code (57212002) based on terminology update. | Terminology | Annual Update |
Value set Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279): Added 4 ICD-10-CM codes (I26.03, I26.04, I26.95, I26.96) based on terminology update. Added 26 SNOMED CT codes based on terminology update. | Terminology | Annual Update |