eMeasure Title

Incidence of Potentially-Preventable Venous Thromboembolism

eMeasure Identifier (Measure Authoring Tool) 114 eMeasure Version number 5.1.000
NQF Number Not Applicable GUID 32cfc834-843a-4f45-b359-8e158eac4396
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward The Joint Commission
Measure Developer The Joint Commission
Endorsed By None
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
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.
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 Outcome
Measure Item Count
Encounter, Performed: Encounter Inpatient
Risk Adjustment
Rate Aggregation
The concept of "failure to prevent" has generated interest in national health policy organizations to identify evidence-based practice that will improve patient safety in the hospital setting (Wachter et al 2001). The incidence of preventable venous thromboembolism (VTE) among hospitalized patients is overwhelming, and contributes to extended hospital stays, and the rising cost of health care. Zhan 2003, states that "VTE was the second most common medical complication of postoperative patients, the second most common cause of excess length of stay, and the third most common cause of excess mortality and excess charges". According to Arnold, D.M. (2001), preventable VTE is defined as "objectively diagnosed Deep Vein Thrombosis (DVT) or Pulmonary Emboli (PE) that occurred in a setting in which thromboprophylaxis was indicated but was either administered inadequately or not administered at all." In spite of formal guidelines, and recommendations for preventative care, pulmonary embolism is still the most common preventable cause of death among hospitalized patients (Wachter et al, 2001).
Clinical Recommendation Statement
Failure to prevent VTE can result in delayed hospital discharge or readmission, increased risk for long-term morbidity from post-thrombotic syndrome, and recurrent thrombosis in the future
Improvement Notation
Improvement noted as a decrease in the rate
Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines. Chest. 2001 Dec;120(6):1964-71.
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.
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.
Wachter, R., Shojania KG, Duncan, B.W., McDonald, K.W., et al. Making health care safer: a critical analysis of patient safety practices; evidence report/ technology assessment No 43. Agency for Healthcare Research and Quality. Publication 01-E0582001.2001. Retrieved March 11, 2015 from http://archive.ahrq.gov/clinic/tp/ptsaftp.htm.
Zhan, C., Miller M.R. Excessive length of stay, charges and mortality attributable to medical injures during hospitalization. JAMA 2003; 290:1868-1874.
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. 

When low dose unfractionated heparin is not administered due to medical reasons, the intended administration route is subcutaneous.

The denominator logic identifies the first confirmatory VTE diagnostic test because there are logic criteria dependent on the timing of the initial confirmation of the VTE diagnosis. Subsequent references to the VTE diagnostic test use occurrencing to ensure that the first confirmatory VTE diagnostic test is consistently used throughout the logic.
Transmission Format
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 with a non-principal diagnosis of venous thromboembolism (VTE)
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
Patients who did not receive VTE prophylaxis prior to the VTE diagnostic test order date
Numerator Exclusions
Not Applicable
Denominator Exceptions
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)