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  • Measure Summary
  • NQMC:010126
  • Oct 2015

Venous thromboembolism (VTE): percent 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 diagnosis testing order date.

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the number of patients diagnosed with confirmed venous thromboembolism (VTE) during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnosis testing order date.

Rationale

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 (Shojania 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 and Miller (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, Khan, and Shrier (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 (Shojania et al., 2001).

Evidence for Rationale

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. PubMed External Web Site Policy

Shojania KG, Duncan BW, McDonald DM, et al, editor(s). Making healthcare safer: a critical analysis of patient safety practices. Prepared by the University of California at San Francisco-Stanford Evidenced-based Practice Center under Contract no. 290-97-0013 (AHRQ Publication NO.01-E058). Rockville (MD): Agency for Healthcare Research and Quality; 2001.  (Evidence report/technology assessment; no. 43). 

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003 Oct 8;290(14):1868-74. PubMed External Web Site Policy

Primary Health Components

Hospital-acquired venous thromboembolism (VTE); prevention

Denominator Description

Patients who developed confirmed venous thromboembolism (VTE) during hospitalization (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who received no venous thromboembolism (VTE) prophylaxis prior to the VTE diagnostic test order date

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Accreditation

Collaborative inter-organizational quality improvement

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Safety

Timeliness

Case Finding Period

Discharges October 1 through June 30

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Diagnostic Evaluation

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Patients who developed confirmed venous thromboembolism (VTE) during hospitalization

Include discharges with an International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-CM) Other Diagnosis Codes of VTE (as defined in the appendices of the original measure documentation)

Exclusions

  • Patients less than 18 years of age
  • Patients who have a length of stay (LOS) greater than 120 days
  • Patients with Comfort Measures Only (as defined in the Data Dictionary) documented
  • Patients enrolled in clinical trials
  • Patients with ICD-10-CM Principal Diagnosis Code of VTE (as defined in the appendices of the original measure documentation)
  • Patients with VTE Present Admission (as defined in the Data Dictionary)
  • Patients with reasons for not administering mechanical and pharmacologic prophylaxis
  • Patients without VTE confirmed by diagnostic testing

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

Inclusions
Patients who received no venous thromboembolism (VTE) prophylaxis prior to the VTE diagnostic test order date

Exclusions
None

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Venous Thromboembolism (VTE) Initial Patient Population Algorithm Flowchart
  • VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism Flowchart

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Unspecified

Original Title

VTE-6: hospital acquired potentially-preventable venous thromboembolism.

Measure Collection Name

National Hospital Inpatient Quality Measures

Measure Set Name

Venous Thromboembolism (VTE)

Submitter

The Joint Commission - Health Care Accreditation Organization

Developer

The Joint Commission - Health Care Accreditation Organization

Funding Source(s)

All external funding for measure development has been received and used in full compliance with The Joint Commission's Corporate Sponsorship policies, which are available upon written request to The Joint Commission.

Composition of the Group that Developed the Measure

Technical advisory panel of stakeholders. The list of participants is available at http://www.jointcommission.org/assets/1/6/VTE_TAP_14-15.pdf External Web Site Policy.

Financial Disclosures/Other Potential Conflicts of Interest

Expert panel members have made full disclosure of relevant financial and conflict of interest information in accordance with the Joint Commission's Conflict of Interest policies, copies of which are available upon written request to The Joint Commission.

Measure Initiative(s)

Hospital Compare

Hospital Inpatient Quality Reporting Program

Quality Check®

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

This measure is reviewed and updated every 6 months.

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Specifications manual for national hospital inpatient quality measures, version 4.3b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; 2014 Apr. various p.

Source(s)

Specifications manual for national hospital inpatient quality measures, version 5.0b. Centers for Medicare & Medicaid Services (CMS), The Joint Commission; Effective 2015 Oct 1. various p.

Measure Availability

Source available from The Joint Commission Web site External Web Site Policy. Information is also available from the QualityNet Web site External Web Site Policy. Check The Joint Commission Web site and QualityNet Web site regularly for the most recent version of the specifications manual and for the applicable dates of discharge.

Companion Documents

The following is available:

  • Hospital compare: a quality tool provided by Medicare. [internet]. Washington (DC): U.S. Department of Health and Human Services; [accessed 2015 May 27]. This is available from the Medicare Web site External Web Site Policy. See the related QualityTools External Web Site Policy summary.

NQMC Status

The Joint Commission originally submitted this NQMC measure summary to ECRI Institute on September 18, 2009. This NQMC summary was reviewed accordingly by ECRI Institute on November 10, 2009.

The Joint Commission informed NQMC that this measure was updated on October 25, 2010 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on January 21, 2011.

This NQMC summary was retrofitted into the new template on May 18, 2011.

The Joint Commission informed NQMC that this measure was updated on June 28, 2012 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on November 29, 2012.

The Joint Commission informed NQMC that this measure was updated on November 21, 2013 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on January 27, 2014.

The Joint Commission informed NQMC that this measure was updated on November 20, 2014 and provided an updated version of the NQMC summary. This NQMC summary was updated accordingly by ECRI Institute on December 22, 2014.

This NQMC summary was updated again by ECRI Institute on September 2, 2015. The information was not verified by the measure developer.

This NQMC summary was edited by ECRI Institute on November 16, 2015.

Copyright Statement

The Specifications Manual for National Hospital Inpatient Quality Measures [Version 5.0b, October, 2015] is the collaborative work of the Centers for Medicare & Medicaid Services and The Joint Commission. The Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services and The Joint Commission. Users of the Specifications Manual for National Hospital Inpatient Quality Measures must update their software and associated documentation based on the published manual production timelines.

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