2028 Reporting PeriodCMS1061v15325eThe proportion of inpatient encounters for patients age 18 years and older, who have at least one surgical procedure performed inside the operating room during the encounter, and who suffer the harm of a postoperative venous thromboembolism (VTE) during the encounter or within 30 days after the first surgical procedure

]]>Inpatient encounters: Includes time in the emergency department, observation, and/or outpatient surgery service when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less.

Surgical procedures: The combined concepts of anesthesia data AND operating room location are used to determine if a surgical procedure occurred. Patients are admitted to the operating room location for any surgical procedure. Using these combined concepts identifies patients at higher risk of developing a postoperative venous thromboembolism (VTE).

First surgical procedure: The first surgical procedure occurring during the inpatient encounter. The measure is specified to assess whether a VTE occurred within 30 days following the first surgical procedure.

Qualifying inpatient encounter: The inpatient encounter that qualifies a patient for the measure denominator. The measure identifies whether a VTE occurs within 30 days of the first surgical procedure that occurs during this qualifying inpatient encounter. Criteria A and B identify instances when that post-operative VTE occurs during the qualifying inpatient encounter, and Criteria C identifies instances when that post-operative VTE occurs during a subsequent encounter, but all of these criteria limit their scope to VTEs occurring within the 30-day window following the first surgical procedure of the qualifying inpatient encounter.

Subsequent encounter: An inpatient encounter occurring within 30 days of the first surgical procedure of the qualifying inpatient encounter. If a patient experiences a VTE during this encounter as defined by numerator Criteria C, the qualifying inpatient encounter is included in the measure numerator. If a subsequent encounter qualifies the preceding qualifying inpatient encounter for inclusion in the measure numerator, then the subsequent encounter cannot qualify as a qualifying inpatient encounter, even if it otherwise satisfies the measure denominator criteria.

A postoperative VTE is defined as a pulmonary embolism (PE) or lower extremity deep vein thrombosis (DVT) experienced by postoperative patients within 30 days following their first surgical procedure. The measure uses four methods to detect a postoperative VTE event, three of which occur within the qualifying inpatient encounter and the fourth occurs in a subsequent encounter. These methods include (1) the use of a diagnostic imaging study and administration of anticoagulants, (2) placement of inferior vena cava filter, (3) diagnosis of VTE not present on admission, or (4) a VTE diagnosed and administration of anticoagulation therapy during a subsequent encounter.

To reduce sensitivity to overdiagnosis bias, diagnosis codes for distal (calf) vein thromboses, solitary subsegmental pulmonary emboli, and unspecified VTE diagnosis codes are not considered as a qualifying VTE diagnosis. The American College of Radiology Expert Panel on Vascular Imaging states, “DVT that is limited to the infrapopliteal calf veins (i.e., below-the-knee or distal DVT) often resolves spontaneously and is rarely associated with pulmonary embolism or other adverse outcome” (Hanley et al., 2018). Similarly, CHEST guidelines state that subsegmental pulmonary emboli is more likely to be a false-positive finding, and clinicians may be safe to refrain from providing anticoagulant therapy if no proximal DVT is present (Stevens et al., 2021).

In Criterion B, due to the risk of bleeding with intracranial or spinal surgeries if VTE prophylaxis is administered, postoperative VTE events will only be considered in the numerator if a diagnostic imaging study is performed after thromboprophylaxis is deemed safe to start which is between 5 days and up to 30 days after the end of the first surgical procedure performed during the qualifying inpatient encounter.

In Criterion C, anticoagulation therapy ordered or prescribed during the subsequent encounter is defined by an anticoagulant medication ordered during the subsequent encounter or an anticoagulant ordered at discharge of the subsequent encounter.

Present on admission (POA) is defined as the conditions present at the time the order for inpatient admission occurs. The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission.

A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission)
A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission)
A POA Indicator of W = clinically undetermined
A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission

Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.

The factor "history of venous thromboembolism (VTE)" included in the measure’s initial risk model is defined as a VTE risk assessment completed with a result of high risk during or before the encounter OR if there was a history of VTE as a diagnosis during or before the encounter.

]]>Inpatient encounters for patients age 18 and older where a surgical procedure was performed inside the operating room during the encounter

]]>Inpatient encounters for patients with a postoperative venous thromboembolism (VTE) within 30 days of the first surgical procedure.

Evidence of a postoperative VTE is determined by either Criterion A, B or C:

Criterion A: A qualifying inpatient encounter, excluding encounters where the first surgical procedure was an intracranial or spinal surgery procedure, with a diagnostic imaging study performed during the qualifying inpatient encounter and within 30 days or less after the end of the first surgical procedure performed and at least one of the following:

An anticoagulation medication order within 24 hours after the end of the diagnostic imaging study during the qualifying inpatient encounter. An anticoagulation medication order is evidenced by:
- Enoxaparin (Lovenox) >80 mg per day
- Apixaban (Eliquis) >=10 mg per day
- Rivaroxaban (Xarelto) >=20 mg per day
- Fondaparinux (Arixtra) >= 5 mg per day
- Dalteparin sodium (Fragmin)>= 10,000 IU per day; or
A heparin intravenous administration within 24 hours after the end of the diagnostic imaging study, with at least 2 activated partial thromboplastin (aPTT) heparin therapy monitoring tests or at least 2 anti factor Xa assays within 35 hours of the start of heparin intravenous therapy administration all which occur during the qualifying inpatient encounter; or
Placement of an inferior vena cava (IVC) filter within 24 hours after the end of the diagnostic imaging study and during the qualifying inpatient encounter; or
A diagnosis of VTE which was not present on admission during the qualifying inpatient encounter.

Criterion B: A qualifying inpatient encounter, where the first surgical procedure was for an intracranial or spinal surgery, and a diagnostic imaging study was performed during the qualifying inpatient encounter and the diagnostic imagining study occurred between 5 days and up to 30 days after the end of the first surgical procedure and at least one of the following:

An anticoagulation medication order within 24 hours after the end of the diagnostic imaging study during the qualifying inpatient encounter. An anticoagulation medication order is evidenced by:
- Enoxaparin (Lovenox) >80 mg per day
- Apixaban (Eliquis) >=10 mg per day
- Rivaroxaban (Xarelto) >=20 mg per day
- Fondaparinux (Arixtra) >= 5 mg per day
- Dalteparin sodium (Fragmin)>= 10,000 IU per day; or
A heparin intravenous administration within 24 hours after the diagnostic imaging study, with at least 2 aPTT heparin therapy monitoring tests or at least 2 anti factor Xa assays within 35 hours of the start of heparin intravenous therapy administration, all of which occur during the qualifying inpatient encounter; or
Placement of an inferior vena cava (IVC) filter within 24 hours after the end of the diagnostic imaging study and during the qualifying inpatient encounter; or
A diagnosis of VTE which was not present on admission during the qualifying inpatient encounter.

Criterion C: A VTE that occurs during a subsequent inpatient encounter and within 30 days or less after the end of the first surgical procedure that occurred during the qualifying inpatient encounter as evidenced by:

A diagnosis of VTE during the subsequent encounter;

and

Anticoagulation therapy ordered or prescribed during the subsequent encounter.

]]>None

]]>Equals Initial Population

]]>Inpatient encounters for

Patient with an obstetric-related diagnosis during the inpatient encounter
Patients with a venous thromboembolism (VTE) diagnosis present on admission
Patients who had extracorporeal membrane oxygenation (ECMO) during the inpatient encounter
Patients with acute brain or spinal injury or hemorrhage present on admission
Patients who had a thrombectomy procedure which occurred before or on the same day as the first surgical procedure during the inpatient encounter
Patients who had intracranial or spinal surgery during the inpatient encounter who were discharged less than 5 days after the end of the surgery
Patients who have a duration of stay less than 2 calendar days

]]>None

]]>Centers for Medicare & Medicaid Services (CMS)]]>Proportion]]>Outcome]]>Decreased score indicates improvement

]]>To calculate the observed hospital-level measure result, divide the total numerator events by the total number of denominator eligible inpatient encounters (denominator-denominator exclusions).To generate the hospital’s risk adjusted rates, CMS uses a regression model to account for sex, age, bleeding disorders, cancer, central venous catheter insertion, history of venous thromboembolism (VTE), obesity, respiratory operations, stroke, and vascular surgery.Only one harm (numerator event) is counted per qualifying inpatient encounter and within the 30-day evaluation period.This eCQM is an episode-based measure. An episode is defined as each inpatient encounter that ends during the measurement period.This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.In-hospital postoperative venous thromboembolism (VTE) encompasses both deep vein thrombosis (DVTs) and pulmonary embolisms (PEs). DVT is associated with poor clinical outcomes, including post-thrombotic syndrome in the leg, anticoagulation-related bleeding, and death (Bysshe et al., 2017). Even though VTE is linked to adverse patient outcomes, there are evidence-based strategies for preventing VTE in hospital settings.

During 2019, 2021, and 2022, patients in the United States experienced 51,586 perioperative VTEs (AHRQ, 2024). This volume of detected, preventable safety events illustrates that there are continued opportunities to reduce the rate of postoperative VTEs.

In terms of processes of care that clinicians can utilize to prevent these safety events, one study found evidence that combining hospital interventions, such as mechanical and pharmacological prophylaxis, can reduce the incidence of DVT among patients undergoing surgery or admitted with trauma (Kakkos et al., 2022). Another study found that interruptions or delays in the prescription of VTE prophylaxis in surgical patients are associated with a 2- to 3- fold increased risk of VTE (Henke et al., 2020). Furthermore, there are clinical guidelines (noted in the clinical recommendation statement section) to support and improve clinical decision making in the prevention of VTE. As such, hospitals have evidence-based strategies to prevent VTEs in the inpatient setting. These findings suggest that there are opportunities to lower postoperative VTE rates through hospital intervention.

]]>None

]]>The measure’s initial risk model will include the following factors:

Sex
Age
Bleeding disorders
Cancer
Central venous catheter insertion
History of venous thromboembolism (VTE)
Obesity
Respiratory operations
Stroke
Vascular surgery

In addition to the above risk factors, which are included in the risk model, the measure also captures the following diagnoses and procedures to support the potential modification of the risk adjustment model in future years:

Diabetes
Fractures
Hip/knee replacement
Hormone therapy use
Immobility
Tobacco use

Please see the Hospital Harm – Postoperative Venous Thromboembolism Risk Adjustment Methodology Report on the eCQI Resource Center website: https://ecqi.healthit.gov

]]>Current clinical practice guidelines recommend the administration of mechanical and/or pharmacologic prophylaxis along with the implementation of a formal strategy within the hospital as appropriate methods to prevent VTE postoperatively.

The American College of Chest Physicians (CHEST) provides the following recommendations as they pertain to general and abdominal-pelvic surgery patients (Gould et al., 2012):

3.6.3. For general and abdominal-pelvic surgery patients at moderate risk for VTE (∼3.0%; Rogers score, > 10; Caprini score, 3-4) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (LDUH) (Grade 2B), or mechanical prophylaxis, preferably with IPC (Grade 2C), over no prophylaxis.

3.6.5. For general and abdominal-pelvic surgery patients at high risk for VTE (∼6.0%; Caprini score, ≥ 5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).

CHEST provides the following recommendation as it pertains to cardiac surgery patients (Gould et al., 2012):

4.4.2 For cardiac surgery patients whose hospital course is prolonged by one or more no hemorrhagic surgical complications, we suggest adding pharmacologic prophylaxis with LDUH or LMWH to mechanical prophylaxis (Grade 2C).

CHEST provides the following recommendation as it pertains to thoracic surgery patients (Gould et al., 2012):

5.4.2 For thoracic surgery patients at high risk for VTE who are not at high risk for perioperative bleeding, we suggest LDUH or LMWH over no prophylaxis (Grade 1C).

CHEST provides the following recommendation as it pertains to craniotomy patients (Gould et al., 2012):

6.4.2 For craniotomy patients at very high risk for VTE (e.g., those undergoing craniotomy for malignant disease), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases (Grade 2C).

CHEST provides the following recommendation as it pertains to spinal surgery patients (Gould et al., 2012):

7.4.2 For patients undergoing spinal surgery at high risk for VTE (including those with malignant disease or those undergoing surgery with a combined anterior-posterior approach), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases (Grade 2C).

The American Society of Hematology (ASH) provides the following guidelines (Anderson et al., 2019): Recommendation 4. For patients undergoing major surgery who receive pharmacologic prophylaxis, the ASH guideline panel suggests using combined prophylaxis with mechanical and pharmacological methods over prophylaxis with pharmacological agents alone.

Recommendation 5. For patients undergoing major surgery, the ASH guideline panel suggests depending on the individual patient and the type of surgical procedure, using combined prophylaxis or mechanical prophylaxis alone.

Recommendation 6. For patients undergoing major surgery, the ASH guideline panel suggests against using inferior vena cava (IVC) filters for prophylaxis of VTE.

Recommendation 10. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH).

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This is a risk adjusted measure. Risk Adjustment Methodology Report: Hospital Harm - Postoperative Venous Thromboembolism Risk-Adjustment Methodology Report.

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