Diagnostic Delay of Venous Thromboembolism in Primary Care

Percentage of episodes for patients 18 years of age and older with documented Venous Thromboembolism (VTE) symptoms in the primary care setting and who had a diagnosis of VTE that occurs > 24 hours and within 30 days following the index primary care visit where symptoms for the VTE were first present.

This electronic Clinical Quality Measure (Measure) and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH). BWH is not responsible for any use of the Measure. BWH makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and BWH has no liability to anyone who relies on such measures or specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. 

LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. 

This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. 

ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

None

None

None

Venous Thromboembolism or VTE disease consists of pulmonary embolism and deep vein thrombosis.  VTE is a deadly disease and more timely treatment can improve patient outcomes (Beckman, et al. 2010).  Evidence from the literature as well as data from our site support this linkage. According to the Centers for Disease Control and Prevention (CDC) up to 900,000 people in USA are affected by VTE which results is more than 100,000 deaths each year (CDC, 2024).  Pulmonary embolism (PE) is an independent predictor of reduced survival for up to 3 months after onset and up to 45% of patients with a PE die within 3 months (Heit JA, 2006). VTE is also associated with increased morbidity, increased health care costs and decreased quality of life (Rathbun S, 2009 and Rabinovich N, 2017).  Long term morbidity includes post-thrombotic syndrome (PTS) and pulmonary hypertension (Kahn SR, 2004). PTS is a chronic complication of deep vein thrombosis (DVT) that develops in 20-50% of patients (Rabinovich N, 2017).  PTS is associated with chronic venous insufficiency and associated signs and symptoms can impose significant morbidity and have a negative impact on quality of life. VTE can also have an impact on subsequent pregnancies, estrogen use, surgery, life insurance and travel (Tran HA, 2019).  The best way to prevent PTS is to prevent the occurrence of DVT, and to provide optimal anticoagulation for the acute phase of DVT once it occurs. The evidence that PE increases morbidity and mortality is robust and DVT is strongly associated with PE. 

Traditionally, there has not been a systematic way to measure the incidence of delayed diagnosis of VTE and therefore the estimates in the literature are based on manual record review and vary widely.  The DOVE eCQM is an automated tool that quantifies delayed diagnosis that builds a foundation for automated VTE risk assessment and prompt treatment to prevent delayed diagnosis and adverse outcomes.

The American Society of Hematology published VTE diagnosis guidelines to provide an evidence-based strategy to efficiently evaluate patients (Lim, 2018, updated 2022).  The goal of these guidelines is to improve diagnostic accuracy by assisting providers with evaluating patients with suspected VTE while reducing unnecessary and more invasive testing (Lim, et al. 2018).  While routine use of guidelines in primary care would likely reduce the number of missed or delayed VTE diagnoses, integration into practice is challenging.  VTE symptoms are nonspecific and often present as symptoms consistent with an underlying chronic illness.  Strategies such as clinical decision support and measurement of diagnostic performance are needed to assist primary care providers with adopting VTE diagnosis guidelines and routinely using them in clinical practice.  Currently, there is no way to measure VTE diagnostic performance.  Metrics are needed to quantify suboptimal VTE diagnostic performance, improved early recognition of VTE symptoms, and ultimately reducing unfavorable VTE outcomes. 

Measuring and reporting delayed VTE diagnosis rates will inform healthcare providers and facilities about opportunities to improve care, strengthen incentives for quality improvement, and ultimately improve the quality of care received by patients.

Venous Thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant and often fatal condition that affects up to 900,000 individuals in the U.S. each year, resulting in over 100,000 deaths (CDC, 2024).  Evidence indicates that prompt diagnosis and timely initiation of treatment can significantly reduce mortality and improve patient outcomes, particularly in primary care where VTE symptoms are frequently under-recognized (Beckman et al., 2010).

A lower score (expressed as a percentage) is indicative of higher quality care.

Reference Type: CITATION

Reference Text: 'Ageno W, Agnelli G, Imberti D, Moia M, Palareti G, Pistelli R, Rossi R, Verso M, MASTER Investigators. Factors associated with the timing of diagnosis of venous thromboembolism: results from the MASTER registry. Thrombosis research. 2008 Jan 1;121(6):751-6.'

Reference Type: CITATION

Reference Text: 'Al-Ani F, Shariff S, Siqueira L, Seyam A, Lazo-Langner A. Identifying venous thromboembolism and major bleeding in emergency room discharges using administrative data. Thromb Res. 2015 Dec;136(6):1195-8. doi: 10.1016/j.thromres.2015.10.035. Epub 2015 Oct 29. PMID: 26553020.'

Reference Type: CITATION

Reference Text: 'Alotaibi GS, Wu C, Senthilselvan A, McMurtry MS. The validity of ICD codes coupled with imaging procedure codes for identifying acute venous thromboembolism using administrative data. Vasc Med. 2015 Aug;20(4):364-8. doi: 10.1177/1358863X15573839. Epub 2015 Apr 1. PMID: 25834115.'

Reference Type: CITATION

Reference Text: 'Baumgartner C, Go AS, Fan D, Sung SH, Witt DM, Schmelzer JR, Williams MS, Yale SH, VanWormer JJ, Fang MC. Administrative codes inaccurately identify recurrent venous thromboembolism: The CVRN VTE study. Thromb Res. 2020 May;189:112-118. doi: 10.1016/j.thromres.2020.02.023. Epub 2020 Mar 5. PMID: 32199174; PMCID: PMC7335977.'

Reference Type: CITATION

Reference Text: 'Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010 Apr;38(4 Suppl):S495-501. doi: 10.1016/j.amepre.2009.12.017. PMID: 20331949.'

Reference Type: CITATION

Reference Text: 'Büller HR, Ten Cate-Hoek AJ, Hoes AW, Joore MA, Moons KG, Oudega R, Prins MH, Stoffers HE, Toll DB, van der Velde EF, van Weert HC; AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) Investigators. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med. 2009 Feb 17;150(4):229-35. PMID: 19221374.'

Reference Type: CITATION

Reference Text: 'Casez P, Labarère J, Sevestre MA, Haddouche M, Courtois X, Mercier S, Lewandowski E, Fauconnier J, François P, Bosson JL. ICD-10 hospital discharge diagnosis codes were sensitive for identifying pulmonary embolism but not deep vein thrombosis. J Clin Epidemiol. 2010 Jul;63(7):790-7. doi: 10.1016/j.jclinepi.2009.09.002. Epub 2009 Dec 2. PMID: 19959332.'

Reference Type: CITATION

Reference Text: 'Chopard R, Albertsen IE, Piazza G. Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA. 2020 Nov 3;324(17):1765-1776. doi: 10.1001/jama.2020.17272. PMID: 33141212.'

Reference Type: CITATION

Reference Text: 'Dalen JE. Pulmonary embolism: what have we learned since virchow?: natural history, pathophysiology, and diagnosis. Chest. 2002 Oct 1;122(4):1440-56.'

Reference Type: CITATION

Reference Text: 'Fang MC, Fan D, Sung SH, Witt DM, Schmelzer JR, Steinhubl SR, Yale SH, Go AS. Validity of Using Inpatient and Outpatient Administrative Codes to Identify Acute Venous Thromboembolism: The CVRN VTE Study. Med Care. 2017 Dec;55(12):e137-e143. doi: 10.1097/MLR.0000000000000524. PMID: 29135777; PMCID: PMC5125903.'

Reference Type: Citation

Reference Text: 'Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thromb Thrombolysis. 2006 Feb;21(1):23-9. doi: 10.1007/s11239-006-5572-y. PMID: 16475038.'

Reference Type: CITATION

Reference Text: 'Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Archives of internal medicine. 2004 Jan 12;164(1):17-26.'

Reference Type: CITATION

Reference Text: 'Kearon C. Diagnosis of suspected venous thromboembolism. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):397-403. doi: 10.1182/asheducation-2016.1.397. PMID: 27913507; PMCID: PMC6142443.'

Reference Type: CITATION

Reference Text: 'Li T, Curtin-Bowen M, Pullman A, Lipsitz S, Syrowatka A, Sainlaire M, Thai T, Businger A, Davis A, Lieberman JR, Blanchfield B, Bates DW, Dykes PC. Testing of a Risk-Standardized Major Bleeding and Venous Thromboembolism Electronic Clinical Quality Measure for Elective Total Hip and/or Knee Arthroplasties. AMIA Annu Symp Proc. 2022 Feb 21;2021:736-743. PMID: 35308961; PMCID: PMC8861692.'

Reference Type: CITATION

Reference Text: 'Monaghan TF, Rahman SN, Agudelo CW, et al. Foundational Statistical Principles in Medical Research: Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value. Medicina (Kaunas). 2021;57(5):503. Published 2021 May 16. doi:10.3390/medicina57050503'

Reference Type: CITATION

Reference Text: 'Ozsu S, Oztuna F, Bulbul Y, Topbas M, Ozlu T, Kosucu P, Ozsu A. The role of risk factors in delayed diagnosis of pulmonary embolism. The American journal of emergency medicine. 2011 Jan 1;29(1):26-32.'

Reference Type: CITATION

Reference Text: 'Pellathy T, Saul M, Clermont G, Dubrawski AW, Pinsky MR, Hravnak M. Accuracy of identifying hospital acquired venous thromboembolism by administrative coding: implications for big data and machine learning research. Journal of Clinical Monitoring and Computing. 2021 Feb 8:1-9.'

Reference Type: Citation

Reference Text: 'Rabinovich A, Kahn SR. The postthrombotic syndrome: current evidence and future challenges. J Thromb Haemost. 2017 Feb;15(2):230-241. doi: 10.1111/jth.13569. Epub 2017 Jan 23. PMID: 27860129.'

Reference Type: Citation

Reference Text: 'Rathbun S. Cardiology patient pages. The Surgeon General's call to action to prevent deep vein thrombosis and pulmonary embolism. Circulation. 2009 Apr 21;119(15):e480-2. doi: 10.1161/CIRCULATIONAHA.108.841403. PMID: 19380627. '

Reference Type: CITATION

Reference Text: 'Righini M, Le Gal G, Bounameaux H. Venous thromboembolism diagnosis: unresolved issues. Thromb Haemost. 2015 Jun;113(6):1184-92. doi: 10.1160/TH14-06-0530. Epub 2014 Dec 11. PMID: 25503584.'

Reference Type: CITATION

Reference Text: 'Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, Elstein AS, Hasler S, Kabongo ML, Krosnjar N, Odwazny R, Wisniewski MF, McNutt RA. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009 Nov 9;169(20):1881-7. doi: 10.1001/archinternmed.2009.333. PMID: 19901140.'

Reference Type: Citation

Reference Text: 'Tran HA, Gibbs H, Merriman E, Curnow JL, Young L, Bennett A, Tan CW, Chunilal SD, Ward CM, Baker R, Nandurkar H. New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Med J Aust. 2019 Mar;210(5):227-235. doi: 10.5694/mja2.50004. Epub 2019 Feb 10. Erratum in: Med J Aust. 2019 Jul;211(2):94. doi: 10.5694/mja2.50260.'

Reference Type: CITATION

Reference Text: 'Uhland H, Goldberg  LM. Pulmonary Embolism: A Commonly Missed Clinical Entity EMBOLISM. Dis Chest. 1964 May;45:533-6. doi: 10.1378/chest.45.5.533. PMID: 14147480'

Reference Type: CITATION

Reference Text: 'Van Maanen R, Kingma AEC, Oudega R, Rutten FH, Moons K, Geersing GJ. Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study. BMJ Open. 2020 Dec 28;10(12):e039913. doi: 10.1136/bmjopen-2020-039913. PMID: 33372074; PMCID: PMC7772307.'

Reference Type: Documentation

Reference Text: 'CDC 2024: Data and Statistics on Venous Thromboembolism | Venous Thromboembolism (Blood Clots) | CDC, Accessed July 31, 2024. https://www.cdc.gov/blood-clots/data-research/facts-stats/index.html'

Reference Type: Documentation

Reference Text: 'Wendy Lim, Grégoire Le Gal, Shannon M. Bates, Marc Righini, Linda B. Haramati, Eddy Lang, Jeffrey A. Kline, Sonja Chasteen, Marcia Snyder, Payal Patel, Meha Bhatt, Parth Patel, Cody Braun, Housne Begum, Wojtek Wiercioch, Holger J. Schünemann, Reem A. Mustafa; American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv 2018; 2 (22): 3226–3256. doi: https://doi.org/10.1182/bloodadvances.2018024828'

A Qualified VTE Encounter is an encounter performed by a qualified provider types with VTE diagnosis code (ICD10). a VTE-related imaging scan is performed during the  encounter within 30 days of the index PCP visit where patient reports VTE symptoms and an anticoagulant medication ordered within 12 hours (before or after) the imaging scan result.

This eCQM is an episode-based measure.  An episode is defined as each eligible encounter for patients aged 18 years and older at the start of the Qualified VTE Encounter during the measurement period.  This measure is to be reported for every eligible encounter during the measurement period.

This eCQM is intended to be reported by integrated health systems with access to both ambulatory and inpatient documentation. The VTE symptoms can be captured through structured, coded data (see “VTE Symptoms” value set). Reporters of the eCQM can also opt to use clinical notes and a Natural Language Processing (NLP) platform that can be freely licensed from Brigham and Women’s Hospital (BWH). This platform, VTExt, is part of the MTERMS platform of Python NLP tools (proprietary to the BWH MTERMS lab). For access to the full MTERMS VTExt tool, please contact the MTERMS lab at BWHMTERMS@bwh.harvard.edu. When using NLP, the MTERMS VTExt tool is not required; however, the expectation for the eCQM is to use the same rule-based approach implemented by BWH. Reporters of the eCQM can use their own code to better suit their organization’s database / note structure / formatting, but such code should use the same rule-based NLP approach as VTExt (i.e., regular expressions).

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.

TBD

All Qualified VTE Encounters in which the patient was aged 18 or older at the start of the Qualified VTE Encounter.

Equals Initial Population.

Exclude qualified VTE encounter with a hospice care service documented within previous 90 Days

Exclude qualified VTE encounter with a palliative care service documented within previous 90 Days

Exclude qualified VTE encounter with another qualified VTE encounter documented within previous 6 months

All qualified VTE encounters in which the VTE diagnosis occurs greater than 24 hours and within 30 days following the index PCP visit.

None

None

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