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Venous Thromboembolism Prophylaxis

Last updated: May 10, 2019

CMS Measure ID: CMS108v8
Version: 8
NQF Number: Not Applicable
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 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

Denominator Statement:

Inpatient hospitalizations for all patients in the initial populationinfo-icon

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

Numerator Statement:

Inpatient hospitalizations for 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

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

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Short Name: VTE-1
Previous Version:
Measure Scoring: Proportion
Measure Type: Process
Improvement Notation:

Improvement noted as an increase in rate

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.

Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Standards Update

  • Updated NQFinfo-icon number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated initial populationinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated denominatorinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator

    Source of Change: Measure Lead

  • Updated denominator exclusionsinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement to align with logic changes to capture patients with comfort measure documented between the day of arrival and the day after hospital admission.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated denominator exclusions statement 'Patients with comfort measures documented anytime between arrival and the day after hospital admission' to indicate comfort measures documented anytime between 'the day of arrival and the day after hospital admission' to align with logic changes.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated numeratorinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Revised numerator statement to align with logic changes to capture patients with documentation reasons for not receiving VTE prophylaxis between the day of arrival and the day after hospital admission.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Removed the diagnosis datatypes for 'Obstetrics', 'Venous Thromboembolism', and 'Obstetrics VTE' to remove redundancy and align with Quality Data Model (QDM)info-icon v5.4 changes.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced function VTEICU.'CalendarDayOfOrDayAfter'() with TJC.'CalendarDayOfOrDayAfter'() to indicate the change in the local library location.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added Interval[start of QualifyingEncounter.relevantPeriod, Global.'ToDate'(start of QualifyingEncounter.relevantPeriod + 2 days)) in Definition 'Encounter With ICU Location Stay 1 Day or More' to align with measure intent to capture patients who were administered VTE prophylaxis on the same date but prior to hospital admission time.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced timing interval ‘1 day or less on or after day of start of Global.'Hospitalization'’ with ‘during 'FromDayOfStartOfHospitalizationToDayAfterAdmission'’ in the 'Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission' definition to capture all timing conditions between the day of arrival and the day after hospital admission.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added a parenthesis around the last union clause of the 'Is In Low Risk for VTE or On Anticoagulant' definition statement to properly group all medications.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3259

  • Replaced function VTEICU.'CalendarDayOfOrDayAfter'() with TJC.'CalendarDayOfOrDayAfter'() to indicate the change in the local library location.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added Interval[start of QualifyingEncounter.relevantPeriod, Global.'ToDate'(start of QualifyingEncounter.relevantPeriod + 2 days)) in Definition 'Encounter With ICU Location Stay 1 Day or More' to align with measure intent to capture patients who were administered VTE prophylaxis on the same date but prior to hospital admission time.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced the 'from/where' return clause with 'with/such that' in the 'VTE Prophylaxis Received on Day of or Day After Admission or Procedure' and 'Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure' definitions to simplify the expression and align with CQL specificationsinfo-icon.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Changed the 'Intervention Comfort Measures on Day of or Day After Procedure' where clause from ‘1 day or less on or after day of’ to ‘during TJC.CalendarDayOfOrDayAfter’ to align with other logic changes to better capture the measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced definitions 'Low Risk for VTE or Anticoagulant Administered During ED Visit' and 'Low Risk for VTE or Anticoagulant Administered on Day of or Day After Admission' with 'Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission' to simplify the logic.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced definitions 'No VTE Prophylaxis Device Due to Medical Reason During ED Visit' and 'No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Admission' with 'No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission' to simplify the logic.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced definitions 'No VTE Prophylaxis Due to Patient Refusal During ED Visit' and 'No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Admission' with 'No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission' to simplify the logic.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced definitions 'No VTE Prophylaxis Medication Due to Medical Reason During ED Visit' and 'No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Admission' into 'No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission to simplify the logic.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added Interval[start of QualifyingEncounter.relevantPeriod, Global.'ToDate'(start of QualifyingEncounter.relevantPeriod + 2 days)) in Definition 'Encounter With ICU Location Stay 1 Day or More' to align with measure intent to capture patients who were administered VTE prophylaxis on the same date but prior to hospital admission time.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced timing interval ‘1 day or less on or after day of start of Global.'Hospitalization'’ with ‘during 'FromDayOfStartOfHospitalizationToDayAfterAdmission'’ in the 'Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission' definition to capture all timing conditions between the day of arrival and the day after hospital admission.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.

    Measure Section: Functions

    Source of Change: ONC Project Tracking System (JIRA): CQM-2835

  • Replaced function VTEICU.ToDate() and function 'To Date'() with function Global.ToDate() to align with tooling updates and make the logic more efficient.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Added function 'CalendarDayOfOrDayAfter'() to the TJC local library and removed it from the VTEICU library to improve harmonizationinfo-icon across measures.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Created function 'FromDayOfStartOfHospitalizationToDayAfterAdmission' to simplify the logic and better align with measure intent.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • ​Updated version number of the VTEICU Library (VTEICU-3.1.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Update to TJC_Overall Library version number (TJC_Overall-3.6.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134): Added 3 RxNorm codes (1549682, 1992427, 2059015).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Atrial Fibrillation/Flutter (2.16.840.1.113883.3.117.1.7.1.202): Added 5 SNOMED CT codes (120041000119109, 15964901000119107, 706923002, 715395008, 720448006).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205): Deleted 1 RxNorm code (1798389).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219): Deleted 1 RxNorm code (978738).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set General Surgery (2.16.840.1.113883.3.117.1.7.1.255): Added 1 SNOMED CT code (764677008) and deleted 3 SNOMED CT codes (27056009, 274032001, 428784009).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Obstetrics (2.16.840.1.113883.3.117.1.7.1.263): Added 1 SNOMED CT code (769087009) and deleted 7 SNOMED CT codes (111443000, 111444006, 111445007, 199032005, 199033000, 288207006, 38331001).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Mental Health Diagnoses (2.16.840.1.113883.3.464.1003.105.12.1004): Deleted 1 SNOMED CT code (79578000). Added 3 ICD-10-CM codes (F53.0, F53.1, F68.A).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45): Changed Exclusion Criteria description from ‘None’ to ‘Palliative Care’ for clarity and to align with chart-abstracted measures.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (JIRA): CQM-3396

  • Created Intensive Care Unit (2.16.840.1.113762.1.4.1029.204) value set with 25 HSLOC codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Intensive Care Unit (2.16.840.1.113762.1.4.1110.23) with Intensive Care Unit (2.16.840.1.113762.1.4.1029.206) grouping value set that includes HSLOC and SNOMED CT extensional value sets (2.16.840.1.113762.1.4.1029.204 and 2.16.840.1.113762.1.4.1110.23).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code systeminfo-icon versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measureinfo-icon Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • ​Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

External Resources