Review of the Stroke and VTE Measure Sets

Review of the Stroke and VTE Measure Sets Vicky Agramonte, RN, MSN IPRO Quality Data Reporting and Improvement Project Presentation to NYS Hospitals January 29, 2013

The QIO Program CMS Leads a national healthcare quality improvement program, implemented locally by an independent network of QIOs in each state and territory. IPRO The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS). 2

The QIO Program Largest federal program dedicated to improving health quality at the local level, Trustworthy partners for the continual improvement of healthcare for all Americans, Focuses on three broad aims: Better patient care, Better population health, Lower healthcare costs through improvement. 3

The QIO Program As the QIO for New York State, IPRO works to achieve the goals of the national QIO program by Convening communities of providers, practitioners and patients across the state to: Share knowledge, Spread best practices, Achieve rapid, wide-scale improvements in patient care. 4

The QIO Program The QIO Program supports patients by: Providing information to help you better manage your own healthcare, Reviewing quality of care complaints, Working with local healthcare providers to make healthcare safer and patient-centered, Listening to you and learning from your experiences, Helping to remove roadblocks between you and better healthcare. 5

The QIO Program The QIO Program supports patients by: Managing and sharing evidence-based best practices, knowledge and tools for improving health quality, efficiency and value. Serving as a change agent for rapid, widespread and significant improvements that contribute to broader national healthcare goals. Facilitating collaborative learning and action that results in better, more patient-centered care. Encouraging beneficiaries to take a more active role in their own healthcare. 6

QIO Program Priorities 2011-2014 Beneficiary- and Family-Centered Care Improving Individual Patient Care by Reducing Healthcare-Associated Infections in Hospitals Healthcare-Acquired Conditions in Nursing Homes Adverse Drug Event and through Quality Reporting Integrating Care for Populations and Communities Improving Health for Populations and Communities 7

Stroke (STK) Measure Set Version 4.2b

Stroke (STK) Measure Set Total of 8 STK Measures Required by both CMS and The Joint Commission effective January 1, 2013 discharges. Measure ID# Measure Short Name Type of Measure STK-4 Thrombolytic Therapy Acute Intervention STK-1 Venous Thromboembolism (VTE) Prophylaxis Early Management STK-5 Antithrombotic Therapy By End of Hospital Day 2 Early Management STK-2 Discharged on Antithrombotic Therapy Discharge STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter Discharge STK-6 Discharged on Statin Medication Discharge STK-8 Stroke Education Discharge STK-10 Assessed for Rehabilitation Discharge 9

Stroke (STK) Measure Set Initial Patient Population Two populations: STK-2, STK-3, STK-4, STK-5, and STK-6 measures: ICD-9-CM Principal Diagnosis code for ischemic stroke required (Appendix A, Table 8.1) STK-1, STK-8, and STK-10 measures: An ICD-9-CM Principal Diagnosis code for ischemic OR hemorrhagic stroke required (Appendix A, Tables 8.1 and 8.2) 10

Stroke (STK) Measure Set Initial Patient Population Excluded Populations All STK measures Age < 18 years Length of Stay > 120 days Patients enrolled in Clinical Trial (stroke patients) Patients admitted for Elective Carotid Intervention 11

Stroke (STK) Measure Set One Acute Measure 12

Stroke (STK) Measure Set STK-4 Thrombolytic Therapy Measures the proportion of acute ischemic stroke patients who arrive at the hospital within 2 hours of time last known well (the last time they were known to be at baseline or without the signs and symptoms of the current stroke) and for whom IV TPA was initiated within 3 hours of time last known well. IV TPA within 3 hours of stroke symptom onset improves outcomes at 3 months Reduced mortality, reduced dependency with ADLs. 13

Stroke (STK) Measure Set STK-4 Thrombolytic Therapy Clock starts with ARRIVAL date/time. Only patients who received care or services in the ED before inpatient admission are included. Exclusions: Time last known well to ED arrival > 2 hours or unknown. Documentation of a Reason for Not Initiating IV Thrombolytic: Patient/family refusal, NIHSS score of zero, or initiation of IV or IA thrombolytic at a transferring hospital Nursing documentation is acceptable. Physician/APN/PA or pharmacist documentation of other reason for not initiating IV TPA. 14

Stroke (STK) Measure Set Two Early Measures 15

Stroke (STK) Measure Set STK-1 VTE Prophylaxis Measures the proportion of ischemic AND hemorrhagic stroke patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given the day of or the day after hospital admission. Stroke patients are at increased risk of developing VTE. Early prophylactic therapies help prevent VTE. 16

Stroke (STK) Measure Set STK-1 VTE Prophylaxis Uses ADMISSION date, not arrival date. VTE prophylaxis inclusions: Low-dose unfractionated heparin Low-molecular-weight heparin (e.g., Lovenox) Intermittent pneumatic compression devices Factor Xa inhibitors (e.g., Arixtra) Warfarin Venous foot pumps 17

Stroke (STK) Measure Set STK-1 VTE Prophylaxis Oral Factor Xa inhibitors (e.g., Xarelto) Requires physician/apn/pa documentation of why Oral Factor Xa inhibitor was administered for VTE prophylaxis (e.g., A- fib/flutter, HX hip or knee replacement surgery, treatment of VTE) Graduated compression stockings - Not sufficient, in and of themselves. Requires additional form of prophylaxis or Reason for No VTE Prophylaxis Hospital Admission. 18

Stroke (STK) Measure Set STK-1 VTE Prophylaxis Exclusions: LOS < 2 days, Comfort Measures Only documented on day of or day after hospital arrival. Documentation of a Reason for No VTE Prophylaxis Hospital Admission: Included in the numerator (NOT excluded). Documentation of a reason for not administering both mechanical AND pharmacological VTE prophylaxis must be present. Reasons must be written by the day after hospital admission. 19

Stroke (STK) Measure Set STK-1 VTE Prophylaxis (continued) Reasons must be documented by a physician/apn/pa or pharmacist (Exception: Patient/family refusal, Risk assessment form showing low risk for VTE). Differences exist in VTE prophylaxis measures and abstraction of VTE prophylaxis elements (STK vs. VTE vs. SCIP): See abstraction guidelines for more information. 20

Stroke (STK) Measure Set STK-5 Antithrombotic Therapy By End of Hospital Day 2 Measures the proportion of ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2. Early antithrombotic therapy reduces stroke mortality and morbidity. 21

Stroke (STK) Measure Set STK-5 Antithrombotic Therapy By End of Hospital Day 2 Clock starts with ARRIVAL date, not admission. Day of arrival = day 1. Documentation of antithrombotic administration must be written on day 1 or 2. Acceptable antithrombotics are listed in Appendix C, Table 8.2. 22

Stroke (STK) Measure Set STK-5 Antithrombotic Therapy By End of Hospital Day 2 Exclusions: LOS < 2 days Comfort Measures Only documented on day of or day after arrival IV or IA TPA Administered at This Hospital or Within 24 Hours Prior to Arrival Documentation of Reason For Not Administering Antithrombotic Therapy By End Of Hospital Day 2: Must be written on day 1 or 2. Reasons must be documented by a physician/apn/pa or pharmacist (Exception: Patient/family refusal). 23

Stroke (STK) Measure Set Five Discharge Measures 24

Stroke (STK) Measure Set STK-2 Discharged on Antithrombotic Therapy Measures the proportion of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Antithrombotic agents reduce stroke mortality, strokerelated morbidity, and stroke recurrence rates. Acceptable antithrombotics same as STK-5 (Appendix C, Table 8.2). 25

Stroke (STK) Measure Set STK-2 Discharged on Antithrombotic Therapy Exclusions: Comfort Measures Only documented Patients transferred to another hospital, left AMA, expired, or discharged to home/facility for hospice Physician/APN/PA or pharmacist documentation of a Reason For Not Prescribing Antithrombotic Therapy at Discharge 26

Stroke (STK) Measure Set STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter Measures the proportion of ischemic stroke patients with a-fib/flutter who are prescribed anticoagulation therapy at hospital discharge. Nonvalvular a-fib (NVAF) is a common arrhythmia and an important risk factor for stroke. Anticoagulants help prevent recurrent stroke in high stroke risk a-fib patients with TIA or prior stroke. 27

Stroke (STK) Measure Set STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter (continued) Atrial Fibrillation/Flutter includes history of a-fib (e.g., remote, persistent, or paroxysmal) or atrial flutter (including history of ablation procedure) OR current a- fib/flutter on EKG. Exceptions: A-fib/flutter that terminated within 8 weeks following CABG, hx transient and entirely reversible episode of atrial fibrillation or flutter due to thyrotoxicosis. 28

Stroke (STK) Measure Set STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter Acceptable anticoagulants include warfarin, direct thrombin inhibitors (e.g., dabigatran), heparin, lowmolecular-weight heparin (e.g., Lovenox), and Oral Factor Xa inhibitors (e.g., Xarelto). ASA alone is NOT acceptable. Exclusions similar to STK-2: Comfort Measures Only documented Patients transferred to another hospital, left AMA, expired, or discharged to home/facility for hospice Physician/APN/PA or pharmacist documentation of a Reason For Not Prescribing Anticoagulation Therapy 29

Stroke (STK) Measure Set STK-6 Discharged on Statin Medication Measures the proportion of ischemic stroke patients with LDL- c 100 mg/dl, or LDL-c not measured, or who were on a lipid-lowering medication prior to hospital arrival that are prescribed a statin at hospital discharge. Intensive lipid-lowering therapy using statins is associated with a dramatic reduction in the rate of recurrent ischemic stroke and major coronary events. 30

Stroke (STK) Measure Set STK-6 Discharged on Statin Medication Comparison of STK-6 to the AMI-10 statin measure: STK-6 automatically includes patients who were on a lipidlowering agent prior to arrival (statin or non-statin), regardless of LDL-c level. In contrast, AMI-10 does not factor in whether a patient was on/not on a lipid-lowering agent prior to arrival. LDL-c testing timeframes: In STK-6, patients with an LDL-c 100 mg/dl within the first 48 hours after arrival or within 30 days prior to arrival are INCLUDED. In contrast, AMI-10 EXCLUDES AMI patients who were not prescribed a statin at discharge but there is an LDL-c < 100 mg/dl within the first 24 hours after arrival or within 30 days prior to arrival. 31

Stroke (STK) Measure Set STK-6 Discharged on Statin Medication (continued) Comparison of STK-6 to the AMI-10 statin measure: Both STK-6 and AMI-10 include patients with no LDL-c measured within the prescribed timeframe. 32

Stroke (STK) Measure Set STK-6 Discharged on Statin Medication Exclusions (for both STK-6 and AMI-10): Comfort Measures Only documented Patients transferred to another hospital, left AMA, expired, or discharged to home/facility for hospice Documentation of a Reason For Not Prescribing Statin Medication at Discharge: Statin allergy Nursing documentation is acceptable Physician/APN/PA or pharmacist documentation of other reason for not prescribing statin at discharge 33

Stroke (STK) Measure Set STK-8 Stroke Education Measures the proportion of ischemic AND hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay which addressed ALL of the following: Activation of emergency medical system/911 if signs or symptoms of stroke occur Follow-up with a physician/apn/pa after discharge Names of all medications prescribed at discharge Risk factors for stroke What to do if warning signs or symptoms of stroke occur 34

Stroke (STK) Measure Set STK-8 Stroke Education Comparison of STK-8 to the HF-1 discharge instructions measure: Both STK-8 and HF-1 include only patients discharged to home and exclude Comfort Measures Only documented. Abstraction of education elements will be very similar to HF-1 discharge instruction elements. Documentation in the medical record must make clear that the patient was given written instructions that address all five areas. Difference from HF-1: In STK-8, credit can be taken if documentation indicates that written instructions were not given because the patient is cognitively impaired and there is no caregiver available. 35

Stroke (STK) Measure Set STK-10 Assessed for Rehabilitation Measures the proportion of ischemic AND hemorrhagic stroke patients who received one or more of the following: Assessment for rehab services by a member of the rehab team Rehab services given by a member of the rehab team during the hospitalization Referral to rehab services following discharge Transfer to a rehab facility 36

Stroke (STK) Measure Set STK-10 Assessed for Rehabilitation Rehab interventions initiated early following stroke can help prevent complications, minimize impairment, and maximize function. Requires documentation by a member of the rehab team. Rehab team is defined as: Physician Physiatrist Neuro-psychologist Physical therapist Occupational therapist Speech and language pathologist 37

Stroke (STK) Measure Set STK-10 Assessed for Rehabilitation Cases with documentation of a reason for not completing a rehabilitation assessment are included in the numerator (NOT excluded). Documentation of symptom resolution without explicit documentation that the patient does not need rehab services does not count as a reason. Exclusions: Comfort Measures Only documented Patients transferred to another hospital, left AMA, expired, or discharged to home/facility for hospice 38

Questions?

Venous Thromboembolism (VTE) Measure Set Version 4.2b

TJC/CMS VTE Core Measure Set Beginning January 2013 CMS will require data collection of the VTE measure set for all IPPS hospitals: VTE 1 - VTE Prophylaxis VTE 2 ICU VTE Prophylaxis VTE 3 VTE Patients with Anticoagulant Overlap VTE 4 VTE Patients Receiving UFH with Monitoring by Protocol/Nomogram VTE 5 VTE Warfarin Therapy Discharge Instruction VTE 6 Hospital-Acquired Potentially Preventable VTE 41

VTE Initial Patient Population 42

3 Initial Sub-Populations All 3 sub-populations include inpatient discharges who are >= 18 years of age and have a Length of Stay (LOS)<=120 days and any ICD-9-CM Diagnosis Code. No VTE diagnosis sub-population (sub-population 1) Principal VTE diagnosis sub-population (sub-population 2) Other VTE Only sub-populations (sub-population 3) 43

Sub-Population 1 No - VTE VTE-1 Venous Thromboembolism Prophylaxis and VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis Any ICD-9-CM Diagnosis Code Except for Principal OR Other Diagnosis Codes of VTE (Table 7.03), Obstetrics (Table 7.02) or Obstetrics-VTE (Table 7.04). 44

VTE-1 Intent & Rationale Intent: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was performed with in a specific time frame. Timeframe being 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. 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. 45

VTE-1 Numerator & Denominator Information 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 Denominator: All patients Variable Key: Length of Stay, Initial ICU Day, ICU LOS, Initial Prophylaxis Day, Initial Surgical Prophylaxis Day 46

VTE-1 Data Elements Data Elements determining Numerator: Reason for No VTE Prophylaxis Hospital Admission Reason for Oral Factor Xa Inhibitor Surgery End Date Surgical Procedure VTE Prophylaxis VTE Prophylaxis Date Data Elements determining Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Date ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Diagnosis Code ICU Admission or Transfer ICU Discharge Date 47

VTE-2 Intent & Rationale Intent: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given within a specific time frame in the Intensive Care Unit (ICU). Timeframe being the day of OR the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) OR surgery end date for surgeries that start the day of OR the day after ICU admission (or transfer). Rationale: Criteria for admission to the Intensive Care Unit (ICU) puts patients at an increased risk for developing VTE and subsequent increased risk of morbidity from PE. 48

VTE-2 Numerator & Denominator Information 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). Denominator: Patients directly admitted or transferred to ICU Variable Key: Length of Stay, ICU LOS, ICU Initial Prophylaxis Day, ICU Initial Surgical Prophylaxis Day, ICU Initial Surgery Day 49

VTE-2 Data Elements Data Elements determining Numerator: Anesthesia Start Date ICU VTE Prophylaxis ICU VTE Prophylaxis Date Reason for No VTE Prophylaxis ICU Admission Reason for Oral Factor Xa Inhibitor - ICU Admission Surgery End Date ICU Admission Surgical Procedure ICU Admission Data Elements determining Denominator: Admission Date Birth date Clinical Trial Comfort Measures Only Discharge Date ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICU Admission or Transfer Date ICU Admission or Transfer ICU Discharge Date 50

Sub-population 2 Principal VTE VTE-3 VTE Patients With Anticoagulation Overlap Therapy VTE-4 VTE Patients Receiving Unfractionated Heparin With Dosages/Platelet Count Monitoring by Protocol VTE-5 Venous Thromboembolism Discharge Instructions ICD-9-CM Principal Diagnosis Codes of VTE (Table 7.03) or Obstetrics-VTE (Table 7.04). 51

VTE-3: VTE Patients with Anticoagulation Overlap Intent & Rationale Intent: This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. Overlap therapy should be administered for at least 5 days with an international normalized ratio (INR) >= 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy. Patients who received less than 5 days of overlap therapy should be discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy. 52

VTE-3: VTE Patients with Anticoagulation Overlap Intent & Rationale (continued) Rationale: For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy because of its rapid onset of action. 53

VTE-3 Numerator & Denominator Information Numerator: Patients who received overlap therapy. Denominator: Patients with confirmed VTE who received warfarin. Included Populations: Discharges with an ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04 Variable Key: Overlap Therapy Days 54

VTE-3 Data Elements Data Elements determining Numerator: INR Value Overlap Therapy Overlap Therapy Start Date Parenteral Anticoagulant End Date Parenteral Anticoagulant Prescribed at Discharge Reason for Discontinuation of Parenteral Therapy Data Elements determining Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Date Discharge Disposition ICD-9-CM Other Diagnosis Codes 55

VTE-3 Data Elements Data Elements determining Numerator: INR Value Overlap Therapy Overlap Therapy Start Date Parenteral Anticoagulant End Date Data Elements determining Denominator (continued): ICD-9-CM Principal Diagnosis Code VTE Confirmed VTE Diagnostic Test Warfarin Administration Parenteral Anticoagulant Prescribed at Discharge Reason for Discontinuation of Parenteral Therapy 56

VTE-3 VTE Therapy Pts with AC Overlap VTE patients with anticoagulation overlap therapy: Patients with acute VTE Either principal (present on admission) or other diagnosis (hospital-acquired) Diagnosis listed on Appendix A, Table 7.03 VTE Diagnosis listed on Appendix A, Table 7.04 Obstetric VTE Overlap Therapy: Warfarin AND Parenteral anticoagulants Treatments listed on Appendix H, Table 2.3 57

Parenteral Anticoagulant Agents 58

VTE-3 VTE Therapy Pts with AC Overlap Numerator: Patients who received warfarin and parenteral anticoagulation overlap therapy 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 overlap therapy OR with documentation of a reason for no overlap therapy Denominator: Patients with a confirmed VTE who receive warfarin 59

VTE-4: VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram Intent & Rationale Intent: This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. Rationale: Subtherapeutic and supratherapeutic levels can lead to thromboembolic or bleeding complications that may increase the patient s length of stay. The use of weight-based nomograms has increased the likelihood that a therapeutic partial prothromboplastin time (aptt) will be achieved within the first 24 to 48 hours of therapy. 60

VTE-4 Numerator & Denominator Information Numerator: Patients who have their IV UFH therapy dosages AND platelet counts monitored according to defined parameters such as a nomogram or protocol. Denominator: Patients with confirmed VTE receiving IV UFH therapy. Included Populations: ICD-9-CM Principal or Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04 61

VTE-4 Data Elements Data Elements determining Numerator: Monitoring Documentation Data Elements determining Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Discharge Date Discharge Disposition ICD-9-CM Other Diagnosis Codes 62

VTE-4 Data Elements (continued) Data Elements determining Numerator: Monitoring Documentation Data Elements determining Denominator: ICD-9-CM Principal Diagnosis Code UFH Therapy Administration VTE Confirmed VTE Diagnostic Test 63

VTE-5: Venous Thromboembolism Warfarin Therapy Discharge Instructions Intent & Rationale Intent: This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home on warfarin with written discharge instructions that address ALL 4 criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. Home is defined as: home, home care, court/law enforcement or home on hospice care. 64

VTE-5: Venous Thromboembolism Warfarin Therapy Discharge Instructions Intent & Rationale (continued) Rationale: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy by utilizing patient education. This is a vital component to achieve successful outcomes, and reduce hospital readmission rate for patients in anticoagulant therapy programs. 65

VTE-5 Numerator & Denominator Information Numerator: Patients with documentation that they OR their caregivers were given written discharge instructions or other educational material about warfarin that addressed ALL of the following: compliance issues dietary advice follow-up monitoring potential for adverse drug reactions and interactions Denominator: Patients with confirmed VTE discharged on warfarin therapy. 66

VTE-5 Data Elements Data Elements determining Numerator: Discharge Instructions Address Compliance Issues Discharge Instructions Address Dietary Advice Discharge Instructions Address Follow-up Monitoring Discharge Instructions Address Potential for Adverse Drug Reactions and Interactions Data Elements determining Denominator: Admission Date Birthdate Clinical Trial Discharge Date Discharge Disposition ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Diagnosis Code 67

VTE-5 VTE Discharge Instructions Discharge instructions address all of the following: Compliance including all of the following statements: Importance of taking warfarin as instructed Importance of monitoring warfarin with scheduled PT/INR Dietary advice-including all of the following statements: Advised a consistent amount of foods with vitamin K rather than avoidance Avoid major changes in dietary habits, or notify a health professional 68

VTE-5 VTE Discharge Instructions Follow-up monitoring including all of the following statements : Name and phone number of health professional/clinic or office monitoring the anticoagulation therapy Next PT/INR laboratory blood draw Potential for adverse drug reactions and interaction including all of the following: Diet and medications can affect PT/INR Do not take or discontinue any medication or OTC medication except on the advice of a physician or pharmacist Warfarin increases the risk of bleeding 69

Sub-population 3 Other Diagnosis Code of VTE VTE-3 VTE Patients with Anticoagulation Overlap Therapy VTE-4 VTE Patients Receiving Unfractionated Heparin With Dosages/Platelet Count Monitoring by Protocol VTE-5 Venous Thromboembolism Discharge Instructions VTE-6 Hospital Acquired Potentially-Preventable VTE ICD-9-CM Other Diagnosis Code of VTE or Obstetrics-VTE 70

VTE-6: Hospital Acquired Potentially- Preventable Venous Thromboembolism Intent & Rationale Intent: This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did NOT receive VTE prophylaxis in a specific time frame. Timeframe being, between hospital admission and the day before the VTE diagnostic testing order date. 71

VTE-6: Hospital Acquired Potentially- Preventable Venous Thromboembolism Intent & Rationale (continued) Rationale: 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. In spite of formal guidelines and recommendations for preventative care, problems remain. 2nd most common post-op complication 2nd most common cause of excess LOS 3rd common cause of excess mortality/charges 72

VTE-6 Numerator & Denominator Information Numerator: Patients who received no VTE prophylaxis prior to the VTE diagnostic test order date. Denominator: Patients who developed confirmed VTE during hospitalization. Included Populations: Discharges with an ICD-9-CM Other Diagnosis Codes of VTE as defined in Appendix A, Table 7.03 or 7.04 73

VTE-6 Data Elements Data Elements determining Numerator: VTE Prophylaxis Status Data Elements determining Denominator: Admission Date Birthdate Clinical Trial Comfort Measures Only Data Elements determining Denominator Continued: ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Diagnosis Code VTE Confirmed VTE Diagnostic Test VTE Present at Admission Discharge Date 74

VTE 6 Aiming for the Denominator VTE 6 is an inverse measure, different than what we are used to. It captures adverse outcomes: Goal is 0% for this measure. Numerator: Patients who develop VTEs because of NO or INSUFFICIENT prophylaxis. Cases with patients who develop VTE despite prophylaxis go in the denominator, which does NOT count against the hospital. 75

Simple VTE Order Set 76

77

UFH Protocol Example VTE nursing-driven, weight-based protocol using anti-xa levels Initial dose: 80 IU/kg (ABW) bolus followed by infusion of 18 units/kg/hr (ABW) Anti-Xa level Response Next level 0.00 0.09 Bolus 25 units/kg; increase infusion by 3 units/kg/hr 6 hours 0.10 0.19 Increase infusion by 2 units/kg/hour 6 hours 0.20 0.29 Increase infusion by 1 units/kg/hour 6 hours 0.30 0.69 NO CHANGE Next am 0.70 0.79 Decrease infusion by 1 units/kg/hour 6 hours 0.80 0.89 STOP INFUSION for 1 hr, then decrease by 2 units/kg/hr 6 hours after restart 0.90 0.99 STOP INFUSION for 1 hr, then decrease by 3 units/kg/hr 6 hours after restart 1.00 1.09 STOP INFUSION for 2 hr, then decrease by 4 units/kg/hr 6 hours after restart 78

References Qualitynet. Specifications Manual for National Hospital Inpatient Quality Measures. Version 4.2 Venous Thromboembolism National Hospital Inpatient Quality Measures. Retrieved September 25, 2012 from https://www.qualitynet.org/dcs/contentserver?c=page&pagename=qnetp ublic%2fpage%2fqnettier2&cid=1141662756099 79

For more information Karen O Leary Project Manager (518) 426-3300 ext 124 koleary@nyqio.sdps.org Vicky Agramonte Project Manager (518) 426-3300 ext 115 vagramonte@ipro.org IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.4-13-04