Generated Narrative: Measure

CQFM Population Basis: Encounter

wg: cqi

url: http://hl7.org/fhir/us/davinci-deqm/Measure/measure-exm108-example

identifier: id: 108 (use: OFFICIAL)

version: 4.0.0

name: DEQMVenousThromboembolismProphylaxis

title: EXM108 - Venous Thromboembolism Prophylaxis

status: active

experimental: true

date: 2022-02-22

publisher: HL7 International / Clinical Quality Information

contact: http://www.hl7.org/Special/committees/cqi

description: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission

UseContexts

jurisdiction: United States of America (ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code#US)

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 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.

approvalDate: 2019-03-08

lastReviewDate: 2019-03-08

effectivePeriod: 2018-01-01 --> 2018-12-31

topic: Health Quality Measure Document (LOINC#57024-2)

library: EXM108 - Venous Thromboembolism Prophylaxis Library

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

scoring: Proportion (MeasureScoring#proportion)

type: Process (MeasureType#process)

rationale: Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008). The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that "the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism" (Shojania, 2001). Despite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008). In a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients (Shojania, 2001). Updated "safe practices" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006). As noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008). Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.

clinicalRecommendationStatement: Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.

improvementNotation: Increased score indicates improvement (MeasureImprovementNotation#increase)

guidance: When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous. Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

group

population

code: Initial Population (MeasurePopulationType#initial-population)

description: Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period

Criteria

-	Language	Expression
*	text/cql-identifier	Initial Population

population

code: Numerator (MeasurePopulationType#numerator)

description: Patients who received VTE prophylaxis: - the day of or the day after hospital admission - the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission Patients who have documentation of a reason why no VTE prophylaxis was given: - between arrival and hospital admission - the day of or the day after hospital admission - the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)

Criteria

-	Language	Expression
*	text/cql-identifier	Numerator

population

code: Denominator (MeasurePopulationType#denominator)

description: All patients in the initial population

Criteria

-	Language	Expression
*	text/cql-identifier	Denominator

population

code: Denominator Exclusion (MeasurePopulationType#denominator-exclusion)

description: * Patients who have a length of stay less than 2 days * Patients with comfort measures documented anytime between arrival and the day after hospital admission * Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission * Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day * Patients with a principal diagnosis of mental disorders or stroke * Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries

Criteria

-	Language	Expression
*	text/cql-identifier	Denominator Exclusion

supplementalData

CQFM Include In Report Type: summary

usage: Supplemental Data (MeasureDataUsage#supplemental-data)

Criteria

-	Language	Expression
*	text/cql-identifier	SDE Ethnicity

supplementalData

CQFM Include In Report Type: summary

usage: Supplemental Data (MeasureDataUsage#supplemental-data)

Criteria

-	Language	Expression
*	text/cql-identifier	SDE Payer

supplementalData

CQFM Include In Report Type: summary

usage: Supplemental Data (MeasureDataUsage#supplemental-data)

Criteria

-	Language	Expression
*	text/cql-identifier	SDE Race

supplementalData

CQFM Include In Report Type: summary

usage: Supplemental Data (MeasureDataUsage#supplemental-data)

Criteria

-	Language	Expression
*	text/cql-identifier	SDE Sex