Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (when indicated in ALL patients) (NQF 0239)

eMeasure Name Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (when indicated in ALL patients) eMeasure Id 2D6656C3-E94B-40AE-B025-E1AABC0FC1FC
Version number 1 eMeasure Set Id 05DCBF43-31A3-49D8-BF2A-B6844331E7EF
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward American Medical Association - Physician Consortium for Performance Improvement
Endorsed by National Quality Forum
Description Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux, or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.
Copyright
© 2010 American Medical Association and/or National Committee for Quality Assurance. All Rights Reserved
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
Rationale
This measure addresses VTE risk based on surgical procedure.  VTE prophylaxis is appropriate for all patients undergoing these procedures regardless of individual patient thromboembolic risk factors.  Additional work is needed to determine if a physician-level measure for VTE prophylaxis can be developed to address individual patient thromboembolic risk factors, in addition to procedural risk, without creating data collection burden.  Duration of VTE prophylaxis is not specified in the measure due to varying guideline recommendations for different patient populations.
Clinical Recommendation Statement
Recommend that mechanical methods of prophylaxis be used primarily in patients who are at high risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis. (Grade 2A).  Recommend against the use of aspirin alone as prophylaxis against VTE for any patient group. (Grade 1A). Recommend consideration of renal impairment when deciding on doses of LMWH, fondaparinux, the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys, particularly in elderly patients and those who are at high risk for bleeding.  (Grade 1C+).  Moderate-risk general surgery patients are those patients undergoing a nonmajor procedure and are between the ages of 40 and 60 years or have additional risk factors, or those patients who are undergoing major operations and are <40 years of age with no additional risk factors . Recommend prophylaxis with LDUH, 5,000 U bid or LMWH <=3,400 U once daily (both Grade 1A).  Higher-risk general surgery patients are those undergoing nonmajor surgery and are >60 years of age or have additional risk factors, or patients undergoing major surgery who are >40 years of age or have additional risk factors. Recommend thromboprophylaxis with LDUH, 5,000 U tid or LMWH, >3,400 U daily (both Grade 1A).  Recommend that thromboprophylaxis be used in all major gynecologic surgery patients (Grade 1A).  For patients undergoing major, open urologic procedures, recommend routine prophylaxis with LDUH twice daily or three times daily (Grade 1A).  Patients undergoing major orthopedic surgery, which includes hip and knee arthroplasty and hip fracture repair, represent a group that is at particularly high risk for VTE, and routine thromboprophylaxis has been the standard of care for >15 years.  Elective total hip replacement: routine use of LMWH, fondaparinux, or adjusted-dose VKA (all Grade 1A).  Elective total knee arthroplasty: routine thromboprophylaxis using LMWH, fondaparinux, or adjusted-dose VKA (all Grade 1A).  Hip fracture surgery: routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), adjusted-dose VKA (Grade 2B), or LDUH (Grade 1B).  For major orthopedic surgical procedures, recommend that a decision about the timing of the initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that particular agent (Grade 1A). For LMWH, there are only small differences between starting preoperatively or postoperatively, both options acceptable (Grade 1A).  Recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery (Grade 1A).  (ACCP)
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW and Ray JG. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on antithrombotic and thrombolytic therapy (ACCP). Chest 2004 Sep;126(3 Suppl):338S-400S.
Definition
LMWH – low molecular weight heparin.  
LDUH – low-dose unfractionated heparin
Definition
Initial Patient Population(s): Patient Age: Patients aged 18 years and older before the start of the measurement period. 
Procedure Performed: Procedures for which venous thromboembolism (VTE) prophylaxis is indicated during the measurement period.
Definition
Denominator(s): 
All surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients.
Definition
Denominator Exclusion(s): N/A
Definition
Numerator(s): 
Surgical patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.
Definition
Denominator Exception(s): 
Documentation of medical reason(s) for patient not receiving any form of VTE prophylaxis (low molecular weight heparin (LMWH), low-dose unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis) within 24 hours prior to incision time or within 24 hours after surgery end time.
Guidance
For this measure, the source of the clinical data will be located in both the hospital EHR and the physician practice EHR.  The denominator is identified by the procedures that are performed by the eligible professional, whereas the clinical data required for the numerator and exceptions will be located in the hospital EHR.  In order to calculate the measure, there may be some abstraction required from the inpatient record to the ambulatory (physician) EHR before the measure can be calculated.  The intent of this measure is to assess whether or not providers ordered VTE  prophylaxis to be given within 24 hours prior to incision time or within 24 hours after procedure end time.  Although the eMeasure specifies "Medication, Administered" or "Device, Applied," this should also include the intent to administer the medication or apply the device in the absence of actual administration or application. For example, if the provider orders the medication to be administered at the appropriate time, yet it is not administered, the provider would still be compliant with the numerator.  Standing orders or verbal orders for VTE prophylaxis are also considered to be numerator compliant.  Anesthesia time is used as a proxy for procedure end time in this measure.
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012