eMeasure Title Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
eMeasure Identifier
(Measure Authoring Tool)
73 eMeasure Version number 1
NQF Number 0373 GUID 6f069bb2-b3c4-4bf4-adc5-f6dd424a10b7
Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Joint Commission
Measure Developer Joint Commission
Endorsed By National Quality Forum
Description
This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.
Copyright
Measure specifications are in the Public Domain.

LOINC(R) is a registered trademark of the Regenstrief Institute.

This material contains SNOMED Clinical Terms (R) (SNOMED CT(c)) copyright 2004-2010 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer
None
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy because of its rapid onset of action. Because the oral anticoagulant warfarin has a very slow onset of action, it cannot be used as mono-therapy for acute VTE. Pretreatment with parenteral anticoagulants prior to initiation of warfarin also avoids an early period of hypercoagulability that can result from the selective inhibition of proteins S and C (which have very short half lives). Warfarin can be initiated on the first day of treatment after the first dose of a parenteral anticoagulant has been given.

Warfarin interferes with the synthesis of vitamin K dependent pro-coagulant factors (factors II, VII, IX, and X) as well as some anticoagulant factors (proteins S and C). It takes several days for warfarin to achieve its effect because time is required for normal coagulation factors to be cleared from plasma. The adequacy of warfarin therapy is monitored by measurement of the international normalized ratio (INR). The INR can sometimes appear prolonged (or “therapeutic”) as soon as 24 hours after the institution of warfarin due to a reduction in factor VII levels, even while factor II levels are still high and the patient is not in fact therapeutically anti-coagulated. Because factor II has a half-life of 60-72 hours, a minimum of five days of parenteral anticoagulation is recommended as “overlap therapy” while warfarin is being initiated. Parenteral therapy should also be continued until the INR is greater than or equal to 2.0, even if this takes longer than five days, so that patients are fully anticoagulated during the period before warfarin takes its full effect.
Clinical Recommendation Statement
Overlap therapy of both warfarin and parenteral therapy is the recommended treatment for VTE patients if there are no contraindications. This therapy should take place over five or more days, until an INR greater than or equal to 2.0 is reached prior to discontinuation of parenteral therapy.
Improvement Notation
An increase in the rate
Reference
Kearon C, Kahn, SR, Agnelli G, Goldhaber S, Raskob, GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease. The Eighth ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2008;133: 454S-545S.
Reference
Sallah S, Thomas DP, Roberts HR. Warfarin and heparin-induced skin necrosis and the purple toe syndrome: infrequent complications of anticoagulant treatment. Thromb Haemost. 1997; 78(2): 785-90.
Reference
Gallus A, Jackaman J, Tillet J et al. Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism. Lancet. 1986 Dec 6;2(8519):1293-6.
Reference
Buller HR, Davidson BL, Decousus DL et al. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med. 2003 Oct 30;349 (18):1695-702.
Reference
Buller HR, Davidson BL, Decousas DL et al. Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann Intern Med. 2004 Jun 1;140(11):867-73.
Reference
Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: The Eighth ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2008 133:160S-198S.
Reference
Caprini JA, Tapson VF, Hyers TM et al. NABOR Steering Committee. Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J of Vasc Surg. 2005 Oct;42(4):726-33.
Definition
None
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.

For date difference calculations, use the LAST (most recent) of the alternative dates as the end date and the EARLIEST of the alternative dates as the start date. The calculation should be performed as end date minus start date.
Transmission Format
None
Initial Patient Population
Patients with a diagnosis code for venous thromboembolism (VTE), a patient age greater than or equal to 18 years, and a length of stay less than or equal to 120 days.
Denominator
Patients with confirmed VTE who received warfarin.
Denominator Exclusions
Patients with comfort measures only documented
Patients discharged to a health care facility for hospice care
Patients discharged to home for hospice care
Patients who expired
Patients who left against medical advice
Patients discharged to another hospital
Patients without warfarin therapy during hospitalization
Patients without VTE confirmed by diagnostic testing
Numerator
Patients who received overlap therapy (warfarin and parenteral anticoagulation):

Five or more days, with an INR greater than or equal to 2 prior to discontinuation of parenteral therapy, or
Five or more days, with an INR less than 2 and discharged on overlap therapy, or
Less than five days and discharged on overlap therapy, or
With documentation of reason for discontinuation of overlap therapy, or
With documentation of a reason for no overlap therapy
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Reporting Stratification

Supplemental Data Elements




Measure Set
eMeasure Venous Thromboembolism (eVTE)