Venous Thromboembolism Prophylaxis

Last updated: July 12, 2017

CMS Measure ID: CMS108v4
Version: 4
NQF Number: 0371
Measure Description:

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

Initial Patient Population:

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

Denominator Statement:

All patients in the initial population

Denominator Exclusions:
  • Patients who have a length of stay less than 2 days
  • Patients with comfort measures documented anytime between arrival and the day after hospital admission
  • 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
  • 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
  • Patients with a principal diagnosis of mental disorders or stroke
  • Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries
Numerator Statement:

Patients who received VTE prophylaxis:

  • the day of or 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

Patients who have documentation of a reason why no VTE prophylaxis was given:

  • between arrival and hospital admission
  • the day of or 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

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE1
Next Version: Venous Thromboembolism Prophylaxis
Previous Version: Venous Thromboembolism Prophylaxis
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

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

When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous.

The construct of Unfractionated Heparin (route: 'Intravenous route') intends to capture continually infused heparin rather than heparin flushes or pushes.

Specifications

Release Notes

Header

  • Copyright updated.
  • eMeasure version number incremented.
  • Revised Initial Population header statement to align with measure logic.
  • Updated rationale and references in measure header.
  • Updated the Numerator header statement to better align with measure logic.

Logic

  • Added logic to Numerator to allow for explicitly modeled medical reasons for the non-administration of VTE prophylaxis (e.g. low risk, INR >3.0) to be sourced from ED visit documentation, similarly to the logic for the provision of a medical reason or patient refusal.
  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the 'Intersection of' operator to specify the selection of the data sets common to all individual statements underneath the 'Intersection of'.
  • Introduced variables $EncounterInpatient, $DiagnosisVTE, $MedicationVTEProphylaxis, $DeviceVTEProphylaxis, $NoMedicationVTEProphylaxisMedicalReason, $NoDeviceVTEProphylaxisMedicalReason, $NoVTEProphylaxisPatientRefusal and $InterventionComfortMeasures to allow re-use of logical expressions and reduce redundancy/complexity.
  • Removed occurrencing and added timing constraint to 'Encounter, Performed: Emergency Department Visit' when this QDM element is used on the right-hand side of a temporal operation, to enforce a constraint that wasn't necessarily achieved through occurrencing alone.
  • Reordered Numerator logic to clearly separate appropriate VTE prophylaxis from exceptional scenarios justifying the non-administration of VTE prophylaxis.Added in-line comments to Numerator logic to clearly identify related logic blocks.
  • Replaced the timing relationship 'starts after start of' with 'starts after or concurrent with start of' in logic criteria establishing a relationship between $EncounterInpatient and 'Encounter, Performed: ICU Admission or Transfer', to allow patients who are directly admitted to the ICU to meet the criteria.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Replaced timing relationship 'during' with 'starts during' where both a start datetime and an end datetime associated with a particular QDM element are not critical to fulfill the measure intent.
  • Replaced timing relationship 'ends before start of' with 'ends before or concurrent with start of' in logic criteria relating 'Encounter, Performed: Emergency Department Visit' and $EncounterInpatient, allowing for the Emergency Department Visit discharge to occur in the same minute as the inpatient admission.
  • Replaced timing relationship 'starts before end of' with 'starts before or concurrent with end of' to ensure the inclusion of the end point of the element on the right-hand side of the criterion.
  • Revised comfort measures logic in Denominator Exclusions to allow for comfort measures starting any time during the ED visit.
  • Revised incorrect value set reference in Numerator logic related to Oral Factor Xa inhibitor administration from 'Hip Fracture Surgery' (OID 2.16.840.1.113883.3.117.1.7.1.258) to 'Knee Replacement Surgery' (OID 2.16.840.1.113883.3.117.1.7.1.261).
  • Revised INR result threshold in Numerator logic from '>3' to '>3.0', to convey a more precise threshold aligned with the usual reporting units for this laboratory test.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Value set Atrial Fibrillation/Flutter (OID 2.16.840.1.113883.3.117.1.7.1.202): Deleted 3 SNOMED codes (312442005, 428076002, 429218009).
  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 138 ICD10PCS codes and 42 SNOMED codes.
  • Value set Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257): Added 5 ICD10PCS codes (0U540ZZ,0U840ZZ,0UB40ZZ,0UB47ZZ,0UB48ZZ) and 15 new SNOMED codes.
  • Value set Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259): Added 57 ICD10PCS codes and 18 SNOMED codes.
  • Value set Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260): Added 2 ICD10PCS codes (00560ZZ,009600Z) and deleted 67 ICD10PCS codes and 5 SNOMED codes.
  • Value set Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261): Added 8 ICD10PCS codes.
  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39): Added 5 RXNORM codes (1361568,1361574,1361577,1362831,1362837).
  • Value set Mental Disorders (2.16.840.1.113883.3.117.1.7.1.262): Added 51 ICD10CM codes and 113 SNOMED codes.
  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 1924 ICD10CM codes, 2 ICD9CM codes (648.33,648.34), and 254 SNOMED codes. Deleted 16 SNOMED codes.
  • Value set Obstetrics VTE (OID 2.16.840.1.113883.3.117.1.7.1.264): Added 8 ICD10CM codes (O03.35, O07.35, O22.8X1, O22.8X2, O22.8X3, O22.8X9, O87.0, O87.3) and 1 SNOMED code (609497003).
  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (OID 2.16.840.1.113883.3.117.1.7.1.134): Updated vale set name from Oral Factor Xa Inhibitor for VTE Prophylaxis to Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment.
  • Value set Unfractionated Heparin (OID 2.16.840.1.113883.3.117.1.7.1.218): Added 2 RXNORM codes (1361226, 1362831).
  • Value set Unfractionated Heparin for VTE prophylaxis ingredient specific (OID 2.16.840.1.113762.1.4.1021.13): Added 1 RXNORM code (235473) and deleted 1 RXNORM code (314659).
  • Value set Venous Thromboembolism (OID 2.16.840.1.113883.3.117.1.7.1.279): Deleted 5 ICD10CM codes (I80.231, I80.232, I80.233, I80.239, I82.210) and 12 SNOMED codes. Added 4 SNOMED codes (1001000119102, 132251000119101, 132251000119106, 132251000119107).

External Resources