eMeasure Title

Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

eMeasure Identifier (Measure Authoring Tool) 73 eMeasure Version number 5.1.000
NQF Number 0373 GUID 6f069bb2-b3c4-4bf4-adc5-f6dd424a10b7
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward The Joint Commission
Measure Developer The Joint Commission
Endorsed By National Quality Forum
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.
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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 Process
Measure Item Count
Encounter, Performed: Encounter Inpatient
Risk Adjustment
Rate Aggregation
For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy because of its rapid onset of action (Buller et al., 2004).  Warfarin can be initiated on the first day of treatment after the first dose of a parenteral anticoagulant has been given. Because the warfarin has a very slow onset of action, it cannot be used as mono-therapy for acute VTE (Ansell et al., 2008). 

The strong (Level I) recommendations to overlap parenteral anticoagulation with oral warfarin therapy in the initial treatment of VTE events is based in part on the known effect of warfarin on the coagulation cascade (Brandjes, et al.,1992). The early increase in the Pro thrombin time (PT) and INR often reflects the laboratory finding of initial reduction in clotting factors of the extrinsic pathway of coagulation resulting in prolongation of the PT/INR, while the patient is still at risk of thromboembolic events due to persistent levels of coagulation factors of the intrinsic pathway and common pathways of coagulation.

The recommendation that heparins and warfarin overlap for a five-day period is based on pharmacokinetic, pharmacologic, pathophysiologic, and clinical evidence as noted by Wittkowsky A.K. (2005). All studies support the pharmacokinetic characteristics of warfarin and the time delay in achieving an antithrombotic effect suggesting the need for overlap of heparin during initial warfarin dosing in order to prevent thrombus extension, embolization to the lungs, death due to Pulmonary Emboli (PE), and the development of complications such as recurrent thromboembolic events and the postthrombotic syndrome. Kearon et al, 2008 also denotes current recommendation for treatment of confirmed VTE to begin with oral warfarin therapy, with combination of initial anticoagulation therapy for a minimum of 5 days and until the INR is >2.0 for at least 24 hours, and then a recommended target rate.
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
Improvement noted as an increase in the rate
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.
Brandjes DP, Heijboer H, Buller HR, et al. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med. 1992; 327:1485-9.
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.  
Wittkowsky AK. Why warfarin and heparin need to overlap when treating acute venous thromboembolism. Dis Mon 2005; 51:112-115.
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. 

In the numerator logic, overlap therapy duration uses four days (instead of five) as a threshold because the subtraction doesn't take into account one of the dates. For example, for a patient started on overlap therapy on 01/01/2016 who was last administered a parenteral anticoagulant on 01/05/2016, the difference between the dates is 4 days, but the number of days the patient was on overlap therapy was 5.

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 and a diagnosis of venous thromboembolism (VTE)
Patients with VTE confirmed through a diagnostic test who received warfarin
Denominator Exclusions
* Patients with comfort measures 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 an acute care facility
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 parenteral therapy OR
* With documentation of a reason for no overlap therapy
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)