Specifications Manual for Joint Commission National Quality Measures (v2023B)
Posted: 02/03/2023

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Measure Information Form
Version 2023B

Measure Information Form

Measure Set: Venous Thromboembolism (VTE)

Set Measure ID: VTE-6

Performance Measure Name: Hospital Acquired Potentially-Preventable Venous Thromboembolism

Description: This measure assesses the number 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 diagnostic 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 (Wachter 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 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, D.M. (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 (Wachter et al 2001).

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Patients who developed confirmed VTE during hospitalization.
Included Populations: Discharges with an ICD-10-CM Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a length of stay greater than 120 days
  • Patients with Comfort Measures Only documented
  • Patients enrolled in clinical trials
  • Patients with ICD-10-CM Principal Diagnosis Code of VTE as defined in Appendix A, Table 7.03 or 7.04
  • Patients with VTE Present at Admission
  • Patients with reasons for not administering mechanical and pharmacologic prophylaxis
  • Patients without VTE confirmed by diagnostic testing

Data Elements:

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: In order to identify areas for improvement, hospitals may want to stratify the numerator cases by patient age, diagnosis, or service designation. Patients that developed a VTE during hospitalization (denominator) that received prophylaxis could be evaluated in a separate analysis to determine if appropriate prophylaxis (modality, start time, duration) was administered.

Sampling: No. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  • Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, et. al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Advances. 2019, Dec;3(23):3898-3944.
  • 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.
  • Baglin TP, White K, Charles A. Fatal pulmonary embolism in hospitalized medical patients. J Clin Pathol. 1997 Jul;50(7):609-10.
  • Dupras D, Bluhm J, Felty C, Hansen C, Johnson T, Lim K, Maddali S, Marshall P, Messner P, Skeik N. Venous thromboembolism diagnosis and treatment. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Jan. 90 p.
  • Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
  • Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S.
  • Gillies TE, Ruckley CV, Nixon SJ. Still missing the boat with fatal pulmonary embolism. Br J Surg. 1996 Oct;83(10):1394-5.
  • Goldhaber SZ, Dunn K, Mac Dougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women’s Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000;118:1680
  • Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e227S-77S.
  • Guyatt, GH, Akl, EA, Crowther, M, Gutterman, D, Schunemann, H Antithromboitic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2)(Supp):7S-47S.
  • Heit JA, Cohen AT, Anderson FA Jr, et al. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the US, Blood (ASH Annual Meeting Abstracts), 2005;106:Abstract 910.
  • Heit JA, O'Fallon WM, Petterson TM et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002 Jun 10;162(11):1245-8.
  • ISTH Steering Committee for World Thrombosis Day. “Thrombosis: A Major Contributor to Global Disease Burden.” Thrombosis Research, vol. 134, no. 5, 2014, pp. 931-938. 
  • Jobin S, Kalliainen L, Adebayo L, Agarwal Z, Card R, Christie B, Haland T, Hartmark M, Johnson P, Kang M, Lindvall B, Mohsin S, Morton C. Venous thromboembolism prophylaxis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Nov. 51 p.
  • Kahn S, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, and Murad MH corresponding author. "Prevention of VTE in Nonsurgical Patients Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." Chest 141.2 Suppl (2012): e195S.
  • Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-94S.
  • Khoury L, Dangodara AA, Lee JA, Lovejoy M, Amin AN. “Implementation of a Mandated Venous Thromboembolism Clinical Order Set Improves Venous Thromboembolism Core Measures.” Hospital Practice (1995), vol. 42, no. 5, 2014, pp. 89-99.
  • Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris T, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores CL, Antithrombotic Therapy for VTE Disease: CHEST Guideline, CHEST (2016), doi: 10.1016/j.chest.2015.11.026.
  • Wachter R, Shojania KG, Duncan BW, McDonald KW, et al. Making health care safer: a critical analysis of patient safety practices; evidence report/ technology assessment No 43. Agency for Healthcare Research and Quality. Publication 01-E0582001.2001. Retrieved October 11, 2011 from http://archive.ahrq.gov/clinic/tp/ptsaftp.htm.
  • Zhan C, Miller MR. Excessive length of stay, charges and mortality attributable to medical injures during hospitalization. JAMA 2003; 290:1868-1874.

Measure Algorithm:
VTE-6_Page1.jpg v3 VTE-6_Page2.jpg v1

VTE-6: Algorithm Narrative

VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism

Numerator: Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date.
Denominator: Patients who developed confirmed VTE during hospitalization.

1. Start processing. Run cases which are included in the VTE Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow through this measure.

2. Check ICD-10-CM Other Diagnosis Codes
  1. If all ICD-10-CM Other Diagnosis Codes are missing or none of them on Table 7.03 or 7.04, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  2. If at least one of the ICD-10-CM Other Diagnosis Codes is on Table 7.03 or 7.04, continue processing and proceed to VTE Present at Admission.
3. Check VTE Present at Admission
  1. If VTE Present at Admission is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If VTE Present at Admission equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If VTE Present at Admission equals No, continue processing and proceed to Comfort Measures Only.
4. Check Comfort Measures Only
  1. If Comfort Measures Only is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Comfort Measures Only equals 1, 2, or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Comfort Measures Only equals 4, continue processing and proceed to Clinical Trial.
5. Check Clinical Trial
  1. If Clinical Trial is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Clinical Trial equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Clinical Trial equals No, continue processing and proceed to VTE Diagnostic Test. 
6. Check VTE Diagnostic Test
  1. If VTE Diagnostic Test is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If VTE Diagnostic Test equals No, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If VTE Diagnostic Test equals Yes, continue processing and proceed to VTE Confirmed.
7. Check VTE Confirmed
  1. If VTE Confirmed is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If VTE Confirmed equals No, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If VTE Confirmed equals Yes, continue processing and proceed to VTE Prophylaxis Status.
8. Check VTE Prophylaxis Status
  1. If VTE Prophylaxis Status is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If VTE Prophylaxis Status equals Yes, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If VTE Prophylaxis Status equals No, continue processing and proceed to Reason for No Administration of VTE Prophylaxis.
9. Check Reason for No Administration of VTE Prophylaxis
  1. If Reason for No Administration of VTE Prophylaxis is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Reason for No Administration of VTE Prophylaxis equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing
  3. If Reason for No Administration of VTE Prophylaxis equals No, the case will proceed to a Measure Category Assignment of E and will be in Numerator Population. Stop processing.

Measure Information Form VTE-6
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Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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