eMeasure Title

Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram

eMeasure Identifier (Measure Authoring Tool) 109 eMeasure Version number 5.1.000
NQF Number Not Applicable GUID bcce43dd-08e3-46c3-bfdd-0b1b472690f0
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward The Joint Commission
Measure Developer The Joint Commission
Endorsed By None
Description
This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
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 2004-2015 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer
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.
Measure Scoring Proportion
Measure Type Process
Measure Item Count
Encounter, Performed: Encounter Inpatient
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
Heparin is commonly involved in adverse drug events (Geerts et al., 2008). Sub-therapeutic and supratherapeutic levels can lead to thromboembolic or bleeding complications that may increase the patient's length of stay. The use of weight-based nomograms has increased the likelihood that a therapeutic partial prothromboplastin time (aPTT) will be achieved within the first 24 to 48 hours of therapy. The risk of recurrent thromboembolism is reduced when a therapeutic level of heparin is reached quickly. Unfractionated heparin (UFH) management by weight-based aPTT adjusted protocols have demonstrated their ability through clinical trials to achieve a therapeutic aPTT more rapidly than with standard UFH dosing without increasing major bleeding (Rashke et al., 1993).

Heparin nomograms are superior compared to routine care in the timely achievement of therapeutic anticoagulation despite the trend toward patients having aPTTs above the target range (http://archive.ahrq.gov/clinic/ptsafety/chap9.htm, retrieved March 13, 2015). Heparin-induced thrombocytopenia (HIT) occurs more commonly in patients who receive UFH than in those who receive low molecular weight heparin (Martel et al., 2005). HIT is defined as an unexplained fall in platelet count (specifically, a 50% fall in platelet count from baseline, even if the platelet count remains above 150 x 109/L) (Warkentin et al., 2003). Platelet counts generally begin to fall 5-10 days after the initiation of heparin therapy. Prompt recognition of HIT is important so that heparin can be discontinued and the risk of venous and arterial thrombosis minimized. To detect HIT, platelet count monitoring is recommended for all patients treated with UFH (Warkentin et al., 2003).
Clinical Recommendation Statement
Heparin-induced thrombocytopenia (HIT) may occur in patients who receive unfractionated heparin (UHF) for treatment of thromboembolism. Prompt recognition of HIT by evaluation of platelet counts can allow for detection of HIT, and the subsequent discontinuation of UFH.  Management of UFH by nomogram/protocol is recommended to decrease the time outside of the therapeutic range.
Improvement Notation
Improvement noted as an increase in rate
Reference
Gandi TK, Shojania KG, Bates DW. Chapter 9. Protocols for High-Risk Drugs: Reducing Adverse Drugs Events Related to Anticoagulants. Retrieved from the World Wide Web at http://archive.ahrq.gov/clinic/ptsafety/chap9.htm accessed on March 13, 2015.
Reference
Geerts WH, Bergquist D., Pineo,GF., Heit, J.A., Samama, CM., Lassen, MR., Colwell, CW. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). CHEST. 2008:133; 381-453.
Reference
Guyatt, G.H., Akl, E.A., Crowther, M., Gutterman, D., Schunemann, H. Antithromboitic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2) (Supp):7S-47S.
Reference
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.
Reference
Martel, N., Lee, J., and Wells, P.S. Risk for heparin induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005 June; 106:2710-2715.
Reference
Raschke RA, Reilly BM, Guidry JR et al. The weight-based heparin dosing nomogram compared with 'standard care' nomogram. Ann Intern Med. 1993 Nov 1; 119(9):874-81.
Reference
Warkentin TE, Roberts RS, Hirsh J, et al. An improved definition of immune heparin-induced thrombocytopenia in postoperative orthopedic patients. Arch Intern Med 2003; 163:2518-24.
Definition
None
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. 

Treatment adjustment by protocol and/or use of a clinical pathway must be specific to unfractionated heparin therapy. Heparin protocols and clinical pathways may include use of a nomogram.
Transmission Format
TBD
Initial 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 and a diagnosis of venous thromboembolism (VTE) 
Denominator
Patients with VTE confirmed through a diagnostic test and receiving IV UFH therapy
Denominator Exclusions
* Patients with comfort measures documented
* Patients discharged to an acute care facility 
* Patients who left against medical advice
* Patients who expired
* Patients discharged to home for hospice care
* Patients discharged to a health care facility for hospice care
Numerator
Patients who have their IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
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 Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
eMeasure Venous Thromboembolism (eVTE)