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Venous Thromboembolism Inpatient Quality Measures

Venous Thromboembolism Inpatient Quality Measures. Howard Shaps, MD, MBA Medical Director Health Care Excel March 5, 2013. Agenda. Background Sub-populations Measures with exclusions and documentation requirements Quality Improvement. Venous Thromboembolism (VTE).

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Venous Thromboembolism Inpatient Quality Measures

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  1. Venous Thromboembolism Inpatient Quality Measures Howard Shaps, MD, MBA Medical Director Health Care Excel March 5, 2013

  2. Agenda • Background • Sub-populations • Measures with exclusions and documentation requirements • Quality Improvement

  3. Venous Thromboembolism (VTE) • New measure set that becomes a mandatory submission • Beginning with January 1, 2013 discharges • Developed via a project between the Joint Commission (TJC) and the National Quality Forum (NQF) • Measures have been tested and extensively studied • Final measures endorsed by the NQF (National Quality Forum) in 2008

  4. Venous Thromboembolism (VTE) • Measures align with the Centers for Medicare & Medicaid Services (CMS) quality initiatives • Hospital Compare • VTE measures will be posted December 2013 • Hospitals that do not report required quality data • At risk for losing 2% of payments by CMS • Private payers likely to follow

  5. VTE Sub-Populations 1. No VTE Sub-Population • Patients with no ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Tables 7.02, 7.03 and 7.04 • Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years • Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days

  6. VTE Sub-Populations • Principal VTE sub-population • Patients with an ICD-9-CM Principal Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04 • Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years • Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days

  7. VTE Sub-Populations 3. Other VTE Only sub-population • Patients with anICD-9-CM Other Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04 • Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years • Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days • The patients cannot have aICD-9-CM Principal Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04

  8. VTE Measures • VTE – 1 Venous Thromboembolism Prophylaxis • VTE – 2 Intensive Care Unit Venous Thromboembolism Prophylaxis • VTE - 3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy • VTE – 4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram • VTE – 5 Venous Thromboembolism Warfarin Therapy Discharge Instructions • VTE – 6 Hospital Acquired Potentially-Preventable Venous Thromboembolism

  9. VTE Sub - Populations 1 - No VTE 2 – Principal VTE VTE 3, 4, and 5 3 – Other VTE VTE 1 and 2 VTE 6

  10. Bob May

  11. VTE - 1 VTE Prophylaxis VTE – 1

  12. VTE - 1 Description • This measure assesses: • The number of patients who received VTE prophylaxis, OR • Have documentation why no VTE prophylaxis was given • The day of or the day after hospital admission OR surgery end date, for surgeries that start the day of OR the day after hospital admission

  13. VTE – 1 Rationale • Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected • The majority of fatal events occur as sudden or abrupt death • It is expected that all medical and surgical patients will receive some form of VTE prophylaxis • More than 2 million Americans develop a VTE each year1 1www.arqh.gov

  14. VTE – 1 Rationale • Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization • 30 days post hospitalization • A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients…. • Found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type1 • The Agency for Healthcare Research and Quality (ARQH) defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients 1Cohen AT, et al. ENDORSE study: a multinational cross-sectional study. Lancet. 2008;371:387-394.

  15. VTE – 1 Rationale • Chances of complications from prophylaxis are small • Prophylaxis is cost-effective • Benefits outweigh the risks • Fatal pulmonary emboli are prevented by thromboprophylaxis1 1Geerts WH, et al. . Prevention of venous thromboembolism.. Chest. 2008; 133:381S-453S.

  16. VTE – 1 Numerator • Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given: • The day of OR the day after hospital admission • The day of OR the day after surgery end date for surgeries that start the day of OR the day after hospital admission • Excluded Populations - None

  17. VTE – 1 Denominator • All patients • Excluded Patients • Patients less than 18 • Patients with LOS less than 120 days • Patients with Comfort Measures Only • Documented on day of or after arrival • Patients enrolled in clinical trials • Patients directly admitted to the ICU, or transferred to the ICU the day of or the day after hospital admission with ICU LOS greater than or equal to one day

  18. VTE – 1 Denominator • Excluded Patients, continued • Principal diagnosis of Mental Disorders • Principal diagnosis of Stroke • These patients should receive prophylaxis other than graduated compression stockings • Any diagnosis of Obstetrics, VTE or Obstetrics VTE • Principle procedure on Surgical Care Improvement Project (SCIP) tables • Prophylaxis differs • Cannot be in SCIP VTE and VTE-1

  19. VTE – 1 Required Physician Documentation • Patient/family refusal • May be documented by a nurse • Must be in the same timeframe as prophylaxis • Refusal of one type of prophylaxis covers all types • Example - If refuse heparin, no need for the documentation of the refusal of mechanical prophylaxis

  20. VTE – 1 Required Physician Documentation • “No VTE given” • Cannot only state the condition, alone • Thrombocytopenia • Patient has IVC filter • Acceptable examples • “Active GI bleed, cannot give Lovenox” • “Angiomax is sufficient and no VTE prophylaxis is needed” • “Will not give enoxaparin” • Must address both types of prophylaxis

  21. VTE – 1 Required Physician Documentation • Other methods to document proper prophylaxis • Comfort Measures Only documented • Documented on admit day/day after/day after surgery • Patient received anticoagulants on day of admission for other reasons • Cannot accept Plavix, Aspirin, Ticlid • Must be correct order route • Warfarin stopped due to high INR

  22. VTE – 1 Frequent Mistakes • Patient has a documented contraindication to pharmacologic prophylaxis • Mechanical prophylaxis not addressed • Mechanical prophylaxis started 2 or more days after admission • Ambulation inferred to be a reason for no prophylaxis • Need documentation as to why both methods not used

  23. Dick Schapp

  24. VTE - 2 ICU VTE Prophylaxis

  25. VTE – 2 Description • This measure assesses the number of patients who received VTE prophylaxis, OR • Have documentation why no VTE prophylaxis was given ________________________________________________________________ • The day of or the day after the initial admission (or transfer) to the Intensive Care Unit, OR • Surgery end date for surgeries that start the day of OR the day after ICU admission (or transfer)

  26. VTE – 2 Expectations • ICU patients will receive some form of VTE prophylaxis • Except if no overnight stay, OR • Reason for no VTE prophylaxis given • Starting on ICU admission date or day after admission

  27. VTE – 2 Rationale • Criteria for admission to the ICU itself, puts patients at an increased risk for developing VTE • Subsequent increased risk of morbidity from PE • Risk factors can be related to the acute illness present • Risk factors may be acquired during the ICU admission • From subsequent medical treatments • Limitations of mobility • Presence of central venous lines • Mechanical ventilation and subsequent pharmacological paralysis

  28. VTE – 2 Numerator • Patients who received VTE prophylaxis, OR have documentation why no VTE prophylaxis was given • The day of or the day after ICU admission (or transfer) • The day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) • Excluded populations: None

  29. VTE – 2 Denominator • Patients directly admitted or transferred to ICU • Excluded • Patients less than 18 years of age • Patients who have a hospital length of stay (LOS) less than two days and greater than 120 days • Patients with Comfort Measures Only documented on day of or day after hospital arrival • Patients enrolled in clinical trials

  30. VTE – 2 Denominator • Excluded, continued • Patients with ICU LOS less than one day without VTE prophylaxis administered and documentation for no VTE prophylaxis • Patients with ICD-9-CM Principal or Other Diagnosis Code of Obstetrics or VTE as defined in Appendix A, Table 7.02, 7.03, or 7.04 • Patients with ICD-9-CM Principal Procedure Code of Surgical Care Improvement Project (SCIP) VTE selected surgeries as defined in Appendix A, Tables5.17, 5.19, 5.20, 5.21, 5.22, 5.23, 5.24 that start the day of or the day after ICU admission or transfer

  31. Derrick Thomas

  32. www.arqh.gov

  33. VTE - 3 VTE Patients with Anticoagulation Overlap Therapy

  34. VTE – 3 Description • Assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy • For patients who received fewer than five days of overlap therapy • Should be discharged on both medications, OR • Have a Reason for Discontinuation of Parenteral Therapy • Overlap therapy should be administered for at least five days • With an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, • Discharged on both medications, OR • Have a Reason for Discontinuation of Parenteral Therapy

  35. VTE – 3 Population • Patients with an acute VTE • Either principal (on arrival) or other diagnosis (in the hospital) • Appendix A, Table 7.03 VTE • Appendix A, Table 7.04 Obstetrics VTE (Patients given Xarelto are excluded)

  36. VTE – 3 Parenteral Anticoagulants • Direct Thrombin Inhibitors: • Agatroban (Acova), Bivalirudin (Angiomax), Lepirudin (Refludan) • Low Molecular Weight Heparins (LMWHs): • Dalteparin (Fragmin), Enoxaparin (Lovenox), Tinzaparin (Innohep) • Unfractionated Heparin – IV or SQ • Factor Xa Inhibitor: • Fondaparinux Sodium (Arixtra)

  37. VTE – 3 Overlap Therapy • Oral Warfarin therapy AND • Parenteral anticoagulants • By either IV or subcutaneous route • Appendix H, Table 2.3

  38. VTE – 3 Rationale • For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy • Rapid onset of action • Warfarin can be initiated on the first day of treatment after the first dose of a parenteral anticoagulant has been given • Warfarin has a very slow onset of action • Cannot be used as mono-therapy for acute VTE

  39. VTE – 3 Rationale • Recommendations to overlap parenteral anticoagulation with oral warfarin therapy in the initial treatment of VTE events • Based in part on the known effect of warfarin on the coagulation cascade • The early increase in the INR • Often reflects the laboratory finding of initial reduction in clotting factors of the extrinsic pathway of coagulation resulting in prolongation of the INR • The patient is still at risk of thromboembolic events due to persistent levels of coagulation factors of the intrinsic pathway and common pathways of coagulation

  40. VTE – 3 Best Practice • Overlap warfarin with parenteral anticoagulants until • 5 days of overlap therapy AND • INR >= 2.0 • If INR < 2.0 after 5 days, continue overlap therapy • The recommendation that heparins and warfarin overlap for a five-day period is based on pharmacokinetic, pharmacologic, pathophysiologic, and clinical evidence1 1Wittkowsky AK. Why warfarin and heparin need to overlap when treating acute venous thromboembolism. Dis Mon 2005; 51:112-115.

  41. VTE – 3 Numerator • Patients who received overlap therapy (warfarin and parenteral anticoagulation): • Five or more days, with an INR greater than or equal to 2 prior to discontinuation of parenteral therapy, OR • Five or more days, with an INR less than 2 and discharged on overlap therapy, OR • Less than five days and discharged on overlap therapy, OR • With documentation of reason for discontinuation of parenteral therapy, OR • With documentation of a reason for no overlap therapy • Excluded: None

  42. VTE – 3 Denominator • Patients with confirmed VTE who received warfarin • Discharges with an ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04

  43. VTE – 3 Denominator • Excluded Population • Less than 18 years of age • Length of stay greater than 120 days • Comfort Measures Only documented • Patients enrolled in clinical trials • Patients discharged to a health care facility or home for hospice care • Patients who expired • Patients who left against medical advice • Patients discharged to another hospital • Patients without warfarin therapy during hospitalization • Patients without VTE confirmed by diagnostic testing

  44. VTE – 3 Acceptable Tests • Venography • Pelvic, femoral and other lower extremity veins • Computed Tomography with Contrast • Chest, abdomen, pelvis, lower extremity veins • Pulmonary arteriography/angiography • MRI/MRV • Chest, abdomen, pelvis, lower extremity veins • Nuclear Medicine Studies – High probability ONLY • Compression Ultrasound

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