Venous Thromboembolism Prophylaxis 11.1.000

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 specifications are in the Public Domain.

LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.

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 et al., 2016). According to the Centers for Disease Control and Prevention (CDC) 2020 statistics, 1-2 per 1000 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 et al. 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).

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 noted as an increase in rate

Reference Type: CITATION

Reference Text: 'Anderson, D. R., Morgano, G. P., Bennett, C., Dentali, F., Francis, C. W., Garcia, D. A., . . . Dahm, P. (2019). American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Advances, 3(23), 3898–3944. https://doi.org/10.1182/bloodadvances.2019000975'

Reference Type: CITATION

Reference Text: 'Beckman, M. G., Hooper, W. C., Critchley, S. E., & Ortel, T. L. (2010). Venous thromboembolism: a public health concern. Am J Prev Med, 38(4 Suppl), S495-501. https://doi.org/10.1016/j.amepre.2009.12.017'

Reference Type: CITATION

Reference Text: 'Cohen, A. T., Tapson, V. F., Bergmann, J. F., et al. (2008). Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet, 371, 387-394.'

Reference Type: CITATION

Reference Text: 'Data and statistics on venous thromboembolism | CDC. (2020, February 12). Retrieved from https://www.cdc.gov/ncbddd/dvt/data.html'

Reference Type: CITATION

Reference Text: 'Geerts, W. H., Bergqvist, D., Pineo, G. F., et al. (2008). Prevention of venous thromboembolism: The Eighth ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 133, 381S-453S.'

Reference Type: CITATION

Reference Text: 'Guyatt, G. H., Akl, E. A., Crowther, M., et al. (2012). Antithrombotic therapy and prevention of thrombosis, 9th edition: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2 Suppl.), 7S-47S.'

Reference Type: CITATION

Reference Text: 'Henke, P. K., Kahn, S. R., Pannucci, C. J., Secemksy, E. A., Evans, N. S., Khorana, A. A., . . . Committee, A. H. A. A. C. (2020). Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association. Circulation, 141(24), e914-e931. https://doi.org/10.1161/CIR.0000000000000769'

Reference Type: CITATION

Reference Text: 'Kahn, S. R., Morrison, D. R., Diendéré, G., Piché, A., Filion, K. B., Klil-Drori, A. J., . . . Geerts, W. (2018). Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database of Systematic Reviews, 2018(4). https://doi.org/10.1002/14651858.cd008201.pub3'

Reference Type: CITATION

Reference Text: 'Kearon, C., Akl, E. A., Comerota, A. J., et al. (2012, February). Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th edition: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2 Suppl.), e419S-e494S.'

Reference Type: CITATION

Reference Text: 'Maynard G. Preventing hospital-associated venous thromboembolism: a guide for effective
quality improvement, 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality;
August 2016. AHRQ Publication No. 16-0001-EF.'

Reference Type: CITATION

Reference Text: 'National Quality Forum. (2006). National voluntary consensus standards for prevention and care of venous thromboembolism: Policy, preferred practices, and initial performance measures—A consensus report. Washington, DC: National Quality Forum.'

Reference Type: CITATION

Reference Text: 'Schünemann, H. J., Cushman, M., Burnett, A. E., Kahn, S. R., Beyer-Westendorf, J., Spencer, F. A., . . . Wiercioch, W. (2018). American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Advances, 2(22), 3198–3225. https://doi.org/10.1182/bloodadvances.2018022954'

Reference Type: CITATION

Reference Text: 'Stevens, S. M., Woller, S. C., Baumann Kreuziger, L., Bounameaux, H., Doerschug, K., Geersing, G. J., . . . Moores, L. K. (2021). Executive summary: Antithrombotic therapy for VTE Disease: second update of the CHEST Guideline and expert panel report. Chest. https://doi.org/10.1016/j.chest.2021.07.056'

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 eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

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 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 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)

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Initial Population

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions"

- Denominator
  - "Initial Population"

Denominator Exclusions

"Encounter Less Than 2 Days"
  union "Encounter with ICU Location Stay 1 Day or More"
  union "Encounter with Principal Diagnosis of Mental Disorder or Stroke"
  union "Encounter with Principal Procedure of SCIP VTE Selected Surgery"
  union "Encounter with Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
  union "Encounter with Intervention Comfort Measures on Day of or Day After Procedure"

Numerator

"Encounter with VTE Prophylaxis Received From Day of Start of Hospitalization To Day After Admission or Procedure"
  union ( "Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
      intersect ( "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of VTE"
          union "Encounter with Prior or Present Procedure of Hip or Knee Replacement Surgery"
      )
  )
  union "Encounter with Low Risk for VTE or Anticoagulant Administered"
  union "Encounter with No VTE Prophylaxis Due to Medical Reason"
  union "Encounter with No VTE Prophylaxis Due to Patient Refusal"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Denominator
- - "Initial Population"

Denominator Exclusions

"Encounter Less Than 2 Days"
  union "Encounter with ICU Location Stay 1 Day or More"
  union "Encounter with Principal Diagnosis of Mental Disorder or Stroke"
  union "Encounter with Principal Procedure of SCIP VTE Selected Surgery"
  union "Encounter with Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
  union "Encounter with Intervention Comfort Measures on Day of or Day After Procedure"

Encounter Less Than 2 Days

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  where Global."LengthInDays" ( QualifyingEncounter.relevantPeriod ) < 2

Encounter with ICU Location Stay 1 Day or More

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  where exists ( QualifyingEncounter.facilityLocations Location
      where Location.code in "Intensive Care Unit"
        and Global."LengthInDays" ( Location.locationPeriod ) >= 1
        and Location.locationPeriod starts during Interval[start of QualifyingEncounter.relevantPeriod, TJC."TruncateTime" ( start of QualifyingEncounter.relevantPeriod + 2 days ) )
  )

Encounter with Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with "Intervention Comfort Measures" ComfortMeasures
    such that Coalesce(start of Global."NormalizeInterval"(ComfortMeasures.relevantDatetime, ComfortMeasures.relevantPeriod), ComfortMeasures.authorDatetime)during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )

Encounter with Intervention Comfort Measures on Day of or Day After Procedure

from
  VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "Intervention Comfort Measures" ComfortMeasures
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
    and Coalesce(start of Global."NormalizeInterval"(ComfortMeasures.relevantDatetime, ComfortMeasures.relevantPeriod), ComfortMeasures.authorDatetime)during day of TJC."CalendarDayOfOrDayAfter" ( 
    end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounter

Encounter with Low Risk for VTE or Anticoagulant Administered

"Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission"
  union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"

Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure

( VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      such that Global."NormalizeInterval" ( FactorXaMedication.relevantDatetime, FactorXaMedication.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( start of QualifyingEncounter.relevantPeriod )
)
  union ( from
      VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      ["Medication, Administered": "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
        and Global."NormalizeInterval" ( FactorXaMedication.relevantDatetime, FactorXaMedication.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( 
        end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
      return QualifyingEncounter
  )

Encounter with No VTE Prophylaxis Due to Medical Reason

( "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
    intersect "No Mechanical VTE Prophylaxis Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
)
  union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
      intersect "No Mechanical VTE Prophylaxis Due to Medical Reason on Day of or Day After Procedure"
  )

Encounter with No VTE Prophylaxis Due to Patient Refusal

"No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission"
  union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"

Encounter with Principal Diagnosis of Mental Disorder or Stroke

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  where exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
      where EncounterDiagnoses.rank = 1
        and ( EncounterDiagnoses.code in "Mental Health Diagnoses"
            or EncounterDiagnoses.code in "Hemorrhagic Stroke"
            or EncounterDiagnoses.code in "Ischemic Stroke"
        )
  )

Encounter with Principal Procedure of SCIP VTE Selected Surgery

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with ( "SCIP VTE Selected Surgery" Procedure
    where Procedure.rank = 1 ) SelectedSCIPProcedure
    such that Global."NormalizeInterval" ( SelectedSCIPProcedure.relevantDatetime, SelectedSCIPProcedure.relevantPeriod ) during QualifyingEncounter.relevantPeriod

Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of VTE

( VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with ["Diagnosis": "Atrial Fibrillation/Flutter"] AtrialFibrillation
      such that AtrialFibrillation.prevalencePeriod starts on or before 
      end of QualifyingEncounter.relevantPeriod
)
  union ( VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
      where exists ( QualifyingEncounter.diagnoses QualifyingEncounterDiagnoses
          where QualifyingEncounterDiagnoses.code in "Atrial Fibrillation/Flutter"
      )
  )
  union ( VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
      with ["Diagnosis": "Venous Thromboembolism"] VTEDiagnosis
        such that VTEDiagnosis.prevalencePeriod starts before start of QualifyingEncounter.relevantPeriod
  )

Encounter with Prior or Present Procedure of Hip or Knee Replacement Surgery

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with ( ["Procedure, Performed": "Hip Replacement Surgery"]
    union ["Procedure, Performed": "Knee Replacement Surgery"] ) HipKneeProcedure
    such that Global."NormalizeInterval" ( HipKneeProcedure.relevantDatetime, HipKneeProcedure.relevantPeriod ) starts on or before 
    end of QualifyingEncounter.relevantPeriod

Encounter with VTE Prophylaxis Received From Day of Start of Hospitalization To Day After Admission or Procedure

( VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with "Pharmacological or Mechanical VTE Prophylaxis Received" VTEProphylaxis
      such that Global."NormalizeInterval" ( VTEProphylaxis.relevantDatetime, VTEProphylaxis.relevantPeriod ) starts during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )
)
  union ( from
      VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      "Pharmacological or Mechanical VTE Prophylaxis Received" VTEProphylaxis
      where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
        and Global."NormalizeInterval" ( VTEProphylaxis.relevantDatetime, VTEProphylaxis.relevantPeriod ) starts during day of TJC."CalendarDayOfOrDayAfter" ( 
        end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
      return QualifyingEncounter
  )

Initial Population

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions"

Intervention Comfort Measures

["Intervention, Order": "Comfort Measures"]
  union ["Intervention, Performed": "Comfort Measures"]

Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with "Low Risk Indicator For VTE" LowRiskForVTE
    such that LowRiskForVTE.LowRiskDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )

Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure

from
  VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "Low Risk Indicator For VTE" LowRiskForVTE
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
    and LowRiskForVTE.LowRiskDatetime during day of TJC."CalendarDayOfOrDayAfter" ( 
    end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounter

Low Risk Indicator For VTE

/*The variable "LowRiskDatetime" is to hold VTE Risk Assessment relevant dateTime, INR Laboratory Test result dateTime, and Anticoagulant Medication administration start dateTime.*/
( ["Assessment, Performed": "Risk for venous thromboembolism"] VTERiskAssessment
    where VTERiskAssessment.result in "Low Risk"
    return {
      id: VTERiskAssessment.id,
      LowRiskDatetime: Global."EarliestOf" ( VTERiskAssessment.relevantDatetime, VTERiskAssessment.relevantPeriod )
    }
)
  union ( ["Laboratory Test, Performed": "INR"] INRLabTest
      where INRLabTest.result > 3.0
      return {
        id: INRLabTest.id,
        LowRiskDatetime: INRLabTest.resultDatetime
      }
  )
  union ( ( ( ["Medication, Administered": "Unfractionated Heparin"] UnfractionatedHeparin
        where UnfractionatedHeparin.route in "Intravenous route"
    )
      union ["Medication, Administered": "Direct Thrombin Inhibitor"]
      union ["Medication, Administered": "Glycoprotein IIb/IIIa Inhibitors"] ) AnticoagulantMedication
      return {
        id: AnticoagulantMedication.id,
        LowRiskDatetime: start of Global."NormalizeInterval" ( AnticoagulantMedication.relevantDatetime, AnticoagulantMedication.relevantPeriod )
      }
  )

Global.Inpatient Encounter

["Encounter, Performed": "Encounter Inpatient"] EncounterInpatient
  where "LengthInDays"(EncounterInpatient.relevantPeriod)<= 120
    and EncounterInpatient.relevantPeriod ends during day of "Measurement Period"

No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal

( "No VTE Prophylaxis Medication Administered or Ordered"
  union "No Mechanical VTE Prophylaxis Performed or Ordered" ) NoVTEProphylaxis
  where NoVTEProphylaxis.negationRationale in "Patient Refusal"

No Mechanical VTE Prophylaxis Due to Medical Reason From Day of Start of Hospitalization To Day After Admission

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with "No Mechanical VTE Prophylaxis Performed or Ordered" NoVTEDevice
    such that NoVTEDevice.negationRationale in "Medical Reason"
      and NoVTEDevice.authorDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )

No Mechanical VTE Prophylaxis Due to Medical Reason on Day of or Day After Procedure

from
  VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No Mechanical VTE Prophylaxis Performed or Ordered" NoVTEDevice
  where NoVTEDevice.negationRationale in "Medical Reason"
    and Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
    and NoVTEDevice.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( 
    end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounter

No Mechanical VTE Prophylaxis Performed or Ordered

["Procedure, Not Performed": "Application of Intermittent Pneumatic Compression Devices (IPC)"]
  union ["Procedure, Not Performed": "Application of Venous Foot Pumps (VFP)"]
  union ["Procedure, Not Performed": "Application of Graduated Compression Stockings (GCS)"]
  union ["Device, Not Ordered": "Intermittent pneumatic compression devices (IPC)"]
  union ["Device, Not Ordered": "Venous foot pumps (VFP)"]
  union ["Device, Not Ordered": "Graduated compression stockings (GCS)"]

No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with "No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal" PatientRefusal
    such that PatientRefusal.authorDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )

No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure

from
  VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No Mechanical or Pharmacological VTE Prophylaxis Due to Patient Refusal" PatientRefusal
  where Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
    and PatientRefusal.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( 
    end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounter

No VTE Prophylaxis Medication Administered or Ordered

["Medication, Not Administered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
  union ["Medication, Not Administered": "Low Molecular Weight Heparin for VTE Prophylaxis"]
  union ["Medication, Not Administered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
  union ["Medication, Not Administered": "Warfarin"]
  union ["Medication, Not Administered": "Rivaroxaban for VTE Prophylaxis"]
  union ["Medication, Not Ordered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
  union ["Medication, Not Ordered": "Low Molecular Weight Heparin for VTE Prophylaxis"]
  union ["Medication, Not Ordered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
  union ["Medication, Not Ordered": "Warfarin"]
  union ["Medication, Not Ordered": "Rivaroxaban for VTE Prophylaxis"]

No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission

VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  with "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
    such that NoVTEMedication.negationRationale in "Medical Reason"
      and NoVTEMedication.authorDatetime during day of VTE."FromDayOfStartOfHospitalizationToDayAfterAdmission" ( QualifyingEncounter )

No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure

from
  VTE."Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  ["Procedure, Performed": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
  where NoVTEMedication.negationRationale in "Medical Reason"
    and Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) ends 1 day after day of start of QualifyingEncounter.relevantPeriod
    and NoVTEMedication.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( 
    end of Global."NormalizeInterval" ( AnesthesiaProcedure.relevantDatetime, AnesthesiaProcedure.relevantPeriod ) )
  return QualifyingEncounter

Numerator

"Encounter with VTE Prophylaxis Received From Day of Start of Hospitalization To Day After Admission or Procedure"
  union ( "Encounter with Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
      intersect ( "Encounter with Prior or Present Diagnosis of Atrial Fibrillation or Prior Diagnosis of VTE"
          union "Encounter with Prior or Present Procedure of Hip or Knee Replacement Surgery"
      )
  )
  union "Encounter with Low Risk for VTE or Anticoagulant Administered"
  union "Encounter with No VTE Prophylaxis Due to Medical Reason"
  union "Encounter with No VTE Prophylaxis Due to Patient Refusal"

Pharmacological or Mechanical VTE Prophylaxis Received

( ["Medication, Administered": "Low Dose Unfractionated Heparin for VTE Prophylaxis"] VTEMedication
    where VTEMedication.route in "Subcutaneous route"
)
  union ["Medication, Administered": "Low Molecular Weight Heparin for VTE Prophylaxis"]
  union ["Medication, Administered": "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
  union ["Medication, Administered": "Warfarin"]
  union ["Medication, Administered": "Rivaroxaban for VTE Prophylaxis"]
  union ["Procedure, Performed": "Application of Intermittent Pneumatic Compression Devices (IPC)"]
  union ["Procedure, Performed": "Application of Venous Foot Pumps (VFP)"]
  union ["Procedure, Performed": "Application of Graduated Compression Stockings (GCS)"]

SCIP VTE Selected Surgery

//'SCIP' stands for Surgical Care Improvement Project
["Procedure, Performed": "General Surgery"]
  union ["Procedure, Performed": "Gynecological Surgery"]
  union ["Procedure, Performed": "Hip Fracture Surgery"]
  union ["Procedure, Performed": "Hip Replacement Surgery"]
  union ["Procedure, Performed": "Intracranial Neurosurgery"]
  union ["Procedure, Performed": "Knee Replacement Surgery"]
  union ["Procedure, Performed": "Urological Surgery"]

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

VTE.Admission without VTE or Obstetrical Conditions

Global."Inpatient Encounter" InpatientEncounter
  where not ( exists ( InpatientEncounter.diagnoses EncounterDiagnoses
        where ( EncounterDiagnoses.code in "Obstetrics"
            or EncounterDiagnoses.code in "Venous Thromboembolism"
            or EncounterDiagnoses.code in "Obstetrics VTE"
        )
    )
  )

VTE.Encounter with Age Range and without VTE Diagnosis or Obstetrical Conditions

( Global."Inpatient Encounter" InpatientEncounter
    where AgeInYearsAt(date from start of InpatientEncounter.relevantPeriod)>= 18
)
  intersect "Admission without VTE or Obstetrical Conditions"

Global.Earliest(period Interval<DateTime>)

if ( HasStart(period)) then start of period 
  else 
end of period

Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)
- - Earliest(NormalizeInterval(pointInTime, period))

Global.HasStart(period Interval<DateTime>)

not ( start of period is null
    or start of period = minimum DateTime
)

Global.HospitalizationWithObservation(Encounter "Encounter, Performed")

Encounter Visit
	let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs
			where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
			sort by 
			end of relevantPeriod
	),
	VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),
	EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
			where LastED.relevantPeriod ends 1 hour or less on or before VisitStart
			sort by 
			end of relevantPeriod
	)
	return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), 
	end of Visit.relevantPeriod]

Global.LengthInDays(Value Interval<DateTime>)

difference in days between start of Value and end of Value

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

if pointInTime is not null then Interval[pointInTime, pointInTime]
  else if period is not null then period 
  else null as Interval<DateTime>

TJC.CalendarDayOfOrDayAfter(StartValue DateTime)

Interval["TruncateTime"(StartValue), "TruncateTime"(StartValue + 2 days))

TJC.TruncateTime(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

VTE.FromDayOfStartOfHospitalizationToDayAfterAdmission(Encounter "Encounter, Performed")

Interval[TJC."TruncateTime" ( start of Global."HospitalizationWithObservation" ( Encounter ) ), TJC."TruncateTime" ( start of Encounter.relevantPeriod + 2 days ) )

code "Risk for venous thromboembolism" ("LOINC Code (72136-5)")
valueset "Application of Graduated Compression Stockings (GCS)" (2.16.840.1.113762.1.4.1110.66)
valueset "Application of Intermittent Pneumatic Compression Devices (IPC)" (2.16.840.1.113762.1.4.1110.65)
valueset "Application of Venous Foot Pumps (VFP)" (2.16.840.1.113762.1.4.1110.64)
valueset "Atrial Fibrillation/Flutter" (2.16.840.1.113883.3.117.1.7.1.202)
valueset "Comfort Measures" (1.3.6.1.4.1.33895.1.3.0.45)
valueset "Direct Thrombin Inhibitor" (2.16.840.1.113883.3.117.1.7.1.205)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "General or Neuraxial Anesthesia" (2.16.840.1.113883.3.666.5.1743)
valueset "General Surgery" (2.16.840.1.113883.3.117.1.7.1.255)
valueset "Glycoprotein IIb/IIIa Inhibitors" (2.16.840.1.113762.1.4.1045.41)
valueset "Graduated compression stockings (GCS)" (2.16.840.1.113883.3.117.1.7.1.256)
valueset "Gynecological Surgery" (2.16.840.1.113883.3.117.1.7.1.257)
valueset "Hemorrhagic Stroke" (2.16.840.1.113883.3.117.1.7.1.212)
valueset "Hip Fracture Surgery" (2.16.840.1.113883.3.117.1.7.1.258)
valueset "Hip Replacement Surgery" (2.16.840.1.113883.3.117.1.7.1.259)
valueset "Injectable Factor Xa Inhibitor for VTE Prophylaxis" (2.16.840.1.113883.3.117.1.7.1.211)
valueset "INR" (2.16.840.1.113883.3.117.1.7.1.213)
valueset "Intensive Care Unit" (2.16.840.1.113762.1.4.1029.206)
valueset "Intermittent pneumatic compression devices (IPC)" (2.16.840.1.113883.3.117.1.7.1.214)
valueset "Intracranial Neurosurgery" (2.16.840.1.113883.3.117.1.7.1.260)
valueset "Intravenous route" (2.16.840.1.113883.3.117.1.7.1.222)
valueset "Ischemic Stroke" (2.16.840.1.113883.3.117.1.7.1.247)
valueset "Knee Replacement Surgery" (2.16.840.1.113883.3.117.1.7.1.261)
valueset "Low Dose Unfractionated Heparin for VTE Prophylaxis" (2.16.840.1.113762.1.4.1045.39)
valueset "Low Molecular Weight Heparin for VTE Prophylaxis" (2.16.840.1.113883.3.117.1.7.1.219)
valueset "Low Risk" (2.16.840.1.113883.3.117.1.7.1.400)
valueset "Medical Reason" (2.16.840.1.113883.3.117.1.7.1.473)
valueset "Mental Health Diagnoses" (2.16.840.1.113883.3.464.1003.105.12.1004)
valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
valueset "Obstetrics" (2.16.840.1.113883.3.117.1.7.1.263)
valueset "Obstetrics VTE" (2.16.840.1.113883.3.117.1.7.1.264)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment" (2.16.840.1.113883.3.117.1.7.1.134)
valueset "Patient Refusal" (2.16.840.1.113883.3.117.1.7.1.93)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Rivaroxaban for VTE Prophylaxis" (2.16.840.1.113762.1.4.1110.50)
valueset "Subcutaneous route" (2.16.840.1.113883.3.117.1.7.1.223)
valueset "Unfractionated Heparin" (2.16.840.1.113883.3.117.1.7.1.218)
valueset "Urological Surgery" (2.16.840.1.113883.3.117.1.7.1.272)
valueset "Venous foot pumps (VFP)" (2.16.840.1.113883.3.117.1.7.1.230)
valueset "Venous Thromboembolism" (2.16.840.1.113883.3.117.1.7.1.279)
valueset "Warfarin" (2.16.840.1.113883.3.117.1.7.1.232)

"Assessment, Performed: Risk for venous thromboembolism" using "Risk for venous thromboembolism (LOINC Code 72136-5)"
"Device, Not Ordered: Graduated compression stockings (GCS)" using "Graduated compression stockings (GCS) (2.16.840.1.113883.3.117.1.7.1.256)"
"Device, Not Ordered: Intermittent pneumatic compression devices (IPC)" using "Intermittent pneumatic compression devices (IPC) (2.16.840.1.113883.3.117.1.7.1.214)"
"Device, Not Ordered: Venous foot pumps (VFP)" using "Venous foot pumps (VFP) (2.16.840.1.113883.3.117.1.7.1.230)"
"Diagnosis: Atrial Fibrillation/Flutter" using "Atrial Fibrillation/Flutter (2.16.840.1.113883.3.117.1.7.1.202)"
"Diagnosis: Venous Thromboembolism" using "Venous Thromboembolism (2.16.840.1.113883.3.117.1.7.1.279)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
"Intervention, Order: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Intervention, Performed: Comfort Measures" using "Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45)"
"Laboratory Test, Performed: INR" using "INR (2.16.840.1.113883.3.117.1.7.1.213)"
"Medication, Administered: Direct Thrombin Inhibitor" using "Direct Thrombin Inhibitor (2.16.840.1.113883.3.117.1.7.1.205)"
"Medication, Administered: Glycoprotein IIb/IIIa Inhibitors" using "Glycoprotein IIb/IIIa Inhibitors (2.16.840.1.113762.1.4.1045.41)"
"Medication, Administered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Administered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Administered: Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment" using "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment (2.16.840.1.113883.3.117.1.7.1.134)"
"Medication, Administered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Administered: Unfractionated Heparin" using "Unfractionated Heparin (2.16.840.1.113883.3.117.1.7.1.218)"
"Medication, Administered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Not Administered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Not Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Not Administered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Not Administered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Not Administered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Not Ordered: Injectable Factor Xa Inhibitor for VTE Prophylaxis" using "Injectable Factor Xa Inhibitor for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.211)"
"Medication, Not Ordered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39)"
"Medication, Not Ordered: Low Molecular Weight Heparin for VTE Prophylaxis" using "Low Molecular Weight Heparin for VTE Prophylaxis (2.16.840.1.113883.3.117.1.7.1.219)"
"Medication, Not Ordered: Rivaroxaban for VTE Prophylaxis" using "Rivaroxaban for VTE Prophylaxis (2.16.840.1.113762.1.4.1110.50)"
"Medication, Not Ordered: Warfarin" using "Warfarin (2.16.840.1.113883.3.117.1.7.1.232)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Not Performed: Application of Graduated Compression Stockings (GCS)" using "Application of Graduated Compression Stockings (GCS) (2.16.840.1.113762.1.4.1110.66)"
"Procedure, Not Performed: Application of Intermittent Pneumatic Compression Devices (IPC)" using "Application of Intermittent Pneumatic Compression Devices (IPC) (2.16.840.1.113762.1.4.1110.65)"
"Procedure, Not Performed: Application of Venous Foot Pumps (VFP)" using "Application of Venous Foot Pumps (VFP) (2.16.840.1.113762.1.4.1110.64)"
"Procedure, Performed: Application of Graduated Compression Stockings (GCS)" using "Application of Graduated Compression Stockings (GCS) (2.16.840.1.113762.1.4.1110.66)"
"Procedure, Performed: Application of Intermittent Pneumatic Compression Devices (IPC)" using "Application of Intermittent Pneumatic Compression Devices (IPC) (2.16.840.1.113762.1.4.1110.65)"
"Procedure, Performed: Application of Venous Foot Pumps (VFP)" using "Application of Venous Foot Pumps (VFP) (2.16.840.1.113762.1.4.1110.64)"
"Procedure, Performed: General or Neuraxial Anesthesia" using "General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743)"
"Procedure, Performed: General Surgery" using "General Surgery (2.16.840.1.113883.3.117.1.7.1.255)"
"Procedure, Performed: Gynecological Surgery" using "Gynecological Surgery (2.16.840.1.113883.3.117.1.7.1.257)"
"Procedure, Performed: Hip Fracture Surgery" using "Hip Fracture Surgery (2.16.840.1.113883.3.117.1.7.1.258)"
"Procedure, Performed: Hip Replacement Surgery" using "Hip Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.259)"
"Procedure, Performed: Intracranial Neurosurgery" using "Intracranial Neurosurgery (2.16.840.1.113883.3.117.1.7.1.260)"
"Procedure, Performed: Knee Replacement Surgery" using "Knee Replacement Surgery (2.16.840.1.113883.3.117.1.7.1.261)"
"Procedure, Performed: Urological Surgery" using "Urological Surgery (2.16.840.1.113883.3.117.1.7.1.272)"

["Patient Characteristic Ethnicity": "Ethnicity"]

["Patient Characteristic Payer": "Payer"]

```
["Patient Characteristic Race": "Race"]
```

["Patient Characteristic Sex": "ONC Administrative Sex"]

eMeasure Venous Thromboembolism (eVTE)

Venous Thromboembolism Prophylaxis

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables