Measure Information Form
**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**
Measure Information Form
Measure Set: Stroke(STK)
Set Measure ID: STK-1
Performance Measure Name: Venous Thromboembolism (VTE Prophylaxis)
Description: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission
Rationale: Stroke patients are at increased risk of developing venous thromboembolism (VTE). One study noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke. Reported rates of occurrence vary depending on the type of screening used. Prevention of VTE, through the use of prophylactic therapies, in at risk patients is a noted recommendation in numerous clinical practice guidelines. For acutely ill stroke patients who are confined to bed, thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux is recommended if there are no contraindications. Aspirin alone is not recommended as an agent to prevent VTE.
Type of Measure: Process
Improvement Noted As: Increase in the rate
Risk Adjustment: No.
Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.
Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.
Measure Analysis Suggestions: None
Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.
Data Reported As: Aggregate rate generated from count data reported as a proportion.
Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.
Included Populations: Not applicable
Excluded Populations: None
Ischemic or hemorrhagic stroke patients
Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.
- Patients less than 18 years of age
- Patients who have a Length of Stay less than 2 days
- Patients who have a Length of Stay greater than 120 days
- Patients with Comfort Measures Only documented on day of or day after hospital arrival
- Patients enrolled in clinical trials
- Patients admitted for Elective Carotid Intervention
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