Incidence of Potentially-Preventable Venous Thromboembolism

Last updated: July 12, 2017

CMS Measure ID: CMS114v4
Version: 4
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

Initial Patient Population:

Patients age 18 and older discharged from hospital inpatient acute care during the measurement period with a length of stay less than or equal to 120 days with a non-principal diagnosis of venous thromboembolism (VTE).

Denominator Statement:

Patients who developed VTE confirmed by a diagnostic test during hospitalization.

Denominator Exclusions:
  • Patients with comfort measures documented
  • Patients with VTE present at admission
  • Patients with reasons for not administering mechanical and pharmacologic prophylaxis
Numerator Statement:

Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Patient Safety
Short Name: VTE6
Next Version: Incidence of Potentially-Preventable Venous Thromboembolism
Previous Version: Incidence of Potentially-Preventable Venous Thromboembolism
Measure Score: Proportion
Improvement Notation:

Improvement noted as a decrease in the rate

Guidance:

CMS recognizes the difficulty in capturing the VTE confirmed concept required in this measure and suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs consider selecting alternative electronic clinical quality measures (eCQMs) to meet program requirements for meaningful use. If suitable alternatives are unavailable, CMS will accept a 0 denominator submission for the eCQM version only for this measure.

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.

Specifications

Release Notes

Header

  • Added guidance statement from CMS regarding the capture of the VTE confirmed concept and its impact on the use of the measure.
  • Copyright updated.
  • eMeasure version number incremented.
  • Revised Initial Population and Denominator Exclusions header statements to align with measure logic.
  • Updated references in header.

Logic

  • Added logic to Denominator Exclusions for the administration of direct thrombin inhibitors and glycoprotein IIb/IIIa inhibitors, as these would be considered reasons for not administering VTE prophylaxis.
  • Added logic to Denominator Exclusions to account for patients with a VTE suspicion starting before inpatient admission.
  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Changed datatype 'Diagnostic Study, Order' to Diagnostic Study, Performed' in Denominator Exclusions logic associated with the 'VTE Diagnostic Test' value set.Removed redundant Denominator Exclusions logic for 'Diagnostic Study, Order' occurring during the ED.
  • 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, $MedicationVTEProphylaxis, $DeviceVTEProphylaxis, $NoMedicationVTEProphylaxisMedicalContraindication, $NoDeviceVTEProphylaxisMedicalContraindication, $NoMedicationDeviceVTEProphylaxisPatientRefusal, $InterventionComfortMeasures and $DiagnosisVTE to allow re-use of logical expressions and reduce redundancy/complexity.
  • Removed administration of IV heparin from Denominator Exclusions, as the administration of this medication at one time during the hospitalization would not necessarily obviate the need to prophylax a patient.
  • 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 Denominator Exclusions logic for enhanced readibility and clarity.Added in-line comments to denominaor exclusions logic to clearly identify distinct groups of exclusions.
  • 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.
  • Revised Denominator Exclusions 'not done' logic to require that a medical contraindication for both pharmacological VTE prophylaxis and mechanical VTE prophylaxis are provided within the same timeframe (during the ED visit or during the inpatient encounter). This change aligns VTE-6/CMS114 with 'not done' logic in VTE-1/CMS108 and VTE-2/CMS190.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Vale Set Direct Thrombin Inhibitor (OID 2.16.840.1.113883.3.117.1.7.1.205): Added value set to this measure.
  • Value Set Glycoprotein IIb/IIIa Inhibitors (OID 2.16.840.1.113762.1.4.1045.41): Added value set to this measure.
  • Value set Intravenous route (OID 2.16.840.1.113883.3.117.1.7.1.222): Removed value set from this measure.
  • Value set Low Dose Unfractionated Heparin for VTE Prophylaxis (OID 2.16.840.1.113762.1.4.1045.39): Added 5 RXNORM codes (1361568,1361574,1361577,1362831,1362837).
  • Value Set Low Molecular Weight Heparin for VTE prophylaxis ingredient specific (OID 2.16.840.1.113762.1.4.1021.12): Added value set to this measure.
  • 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): Removed value set from this measure.
  • 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).
  • Value set VTE Confirmed (OID 2.16.840.1.113883.3.117.1.7.1.407): Deleted 37 SNOMED codes; added 5 SNOMED codes (1001000119102, 132251000119101, 132251000119106, 132301000119107, 57834008).
  • Value set Warfarin-only ingredient specific (OID 2.16.840.1.113762.1.4.1021.10): Added value set to this measure.

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