Into the Abyss: Troubleshooting VTE-1 Venous Thromboembolism Prophylaxis (CMS108)

Almost every hospital participating in the CMS Inpatient Quality Reporting program tracks VTE-1 (Venous Thromboembolism Prophylaxis) for electronic clinical quality measure (eCQM) reporting. And almost every hospital struggles to understand the reason why patients aren’t qualifying for their Numerator population.The short answer?

The logic is cumbersome, complicated and quite lengthy (eight pages)! It is filled with timing requirements, diagnosis criteria and multiple layers of logic, not to mention the 50 different data elements and value sets. What should be a straightforward measurement of VTE prophylaxis is complicated by the abyss of complicated logic.

It’s no surprise that one of the most frequent questions I get is, “Why can’t they just tell us what they are looking for so we can figure out how to improve?”

So, I'm going to do that for you and tell you what the measure specification and reporting agencies are looking for. Once you get your thinking organized, the logic will become clearer and your results easier to understand and troubleshoot.

Are you ready to get started?

Before we begin, here is a link to the VTE-1 specification details on the eCQI Resource Center. Follow along with your copy as we go along.

VTE-1 has logic for the following populations: Initial Patient Population (IPP), Denominator, Denominator Exclusions, and Numerator. There are no Denominator Exceptions.

See Also: How to Read an eCQM Specification

The first step is identifying the IPP and understanding how patients qualify for that population. The IPP is made up of patients that meet all the following criteria:

1. Inpatient encounter with a discharge date during the reporting period.
2. Patient’s age is 18 years or older when they are admitted.
3. Does not have a VTE, Pulmonary Embolism or Obstetrical diagnosis. Any patients with these diagnoses are excluded from the IPP. Note: These are not in the ‘exclusions’ population, these patients simply don’t qualify for the IPP.

Next is the Denominator. The good news is that the denominator logic is the same as the IPP so there’s no additional logic to understand. Patients in the IPP just carry over to the Denominator.

Now we have Denominator Exclusions which are considered before the patient makes the Numerator and removes patients based on certain conditions, procedures, etc.

You can exclude patients from the denominator if they:

1. Have a length of stay less than two days
2. Were in the ICU for one or more days
3. Have a mental disorder, hemorrhagic or ischemic stroke as the PRINCIPAL diagnosis. Note: The key word here is Principal, the diagnosis must be flagged as principal to exclude the patient.

Next, let’s remove some surgical patients. The following group of surgeries exclude the patient from the Denominator only if the surgery is flagged as the PRINCIPAL procedure: Gynecological, Hip Fracture, Hip Replacement, Intracranial Neurosurgery, Knee Replacement, Urological and General Surgeries.

And there are even more exclusions to the Denominator population.

• Remove any patient with Comfort Measures documented from the day of or the day after they were admitted to the hospital.
• Remove patients with a surgery during the hospital stay. They may also be removed if comfort measures was documented on the day of or day after the surgery.

Now that we’ve excluded those patients we are left with the “true denominator” population; some of these patients will qualify for the Numerator and some won’t. We call the patients who don’t qualify for the Numerator the “fallouts.” The fallouts are the patients that you need to evaluate. The fewer fallouts, the better.

I’ll walk you through tricks for understanding and troubleshooting fallouts, but I’ll warn you, this isn’t always easy to do. To make it more complicated, this is where the CQL abyss really opens-up and you must dive right in! There is no right or wrong way to do this, the end goal is to understand the logic.

First, there are two timing factors that must be considered and understood before getting started:

Global.Hospitalization is the time the patient enters the FACILITY through the time of discharge. This includes the time they spent in the Emergency Department (ED) (if applicable), Observation (OBS) (if applicable), and as an admitted inpatient.

Global.InpatientEncounter is the time the patient is admitted as an inpatient through the time of discharge. It does not include the time spent in ED and/or OBS.

Note: These timing factors apply to almost every piece of logic and can impact whether the patient qualifies or falls out. Always double check the timing requirements when troubleshooting.

A patient can qualify for the VTE-1 Numerator in several ways. When looking at your fallouts, here are a few questions to consider for determining why the patient didn’t meet the Numerator requirements, and to identify areas for improvement:

1. If the patient didn’t receive prophylaxis, was a contraindication documented on both pharmacological prophylaxis and mechanical prophylaxis?

a. Yes = Numerator
b. No = Fallout

If a patient is not administered pharmacological prophylaxis and no mechanical prophylaxis is applied, then BOTH must have a contraindication documented. And don’t forget about the dreaded negation. Both instances of documentation need the code for the contraindication and the code for negation (that’s a discussion for another blog).

Note: Beware of the timing on this! Both instances of contraindication documentation must be completed by the end of the day after the patient was admitted as an inpatient.

2. Was the mechanical device applied or medication administered and was it applied or administered at a time that falls between the patient’s admission to the facility until the day after the patient was admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

3. Did the patient have an anticoagulant administered at some point from the time they entered the facility until the day after they were admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

4. Did the patient have an anticoagulant administered on the day of or the day after a procedure while admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

5. Was “Low Risk” for VTE documented at any point from the patient’s admission to the facility until the day after they were admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

6. Did the provider document that the patient was “Low Risk” for VTE on the day they had a procedure until the day after a procedure they had while admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

Here’s some crazy questions around the criteria involving Oral Factor Xa Inhibitor. The logic for this involves several data elements. This is where some organized thinking will be beneficial!

7. Did the patient receive Oral Factor Xa Inhibitor, and did they have either an Atrial Fibrillation or Flutter Diagnosis, or a Hip or Knee Replacement Surgery during the inpatient encounter?

a. Yes = Numerator
b. No = Fallout

8. Did the patient receive Oral Factor Xa Inhibitor on the day of or the day after an inpatient procedure and did the procedure require general anesthesia?

a. Yes = Numerator
b. No = Fallout

And a final question to consider for lab tests:

9. Did the patient have an INR > 3 resulted from the time they arrived at the facility through the day after they were admitted as an inpatient?

a. Yes = Numerator
b. No = Fallout

I would love to tell you that this is the complete list of questions to consider for VTE-1, but alas, there are just too many to fit in one blog. The good news is that these questions highlight some of the more complicated sections of logic and will hopefully help get you started in understanding your fallouts. Once you know why you have fallouts, you can look at workflows, mapping issues, provider education and other factors that may improve your performance rate.