eCQM Title

Diagnostic Delay of Venous Thromboembolism (DOVE) in Primary Care

eCQM Identifier (Measure Authoring Tool)

1173

eCQM Version Number

1.0.000

NQF Number

Not Applicable

GUID

bd7ed96b-6e53-4276-8840-842fe56f06b3

Measurement Period

January 1, 20XX through December 31, 20XX

Measure Steward

Brigham and Womens Health

Measure Developer

Brigham and Womens Health

Endorsed By

None

Description

This eCQM assesses the rate of delayed diagnosis of VTE in the primary care setting. Delayed diagnosis is defined as diagnosis of VTE that occurs >24 hours following the index primary care visit where symptoms for the VTE were first present (within 30 days). The target population for this measure is all patients, 18 years and older, across all payers.

This electronic Clinical Quality Measure (eCQM) and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH). BWH is not responsible for any use of the Measure. BWH makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and BWH has no liability to anyone who relies on such measures or specifications.

Disclaimer

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Measure Scoring

Proportion

Measure Type

Outcome

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

VTE is a serious, preventable public health problem affecting approximately 300,000–600,000 individuals in the U.S. each year and requires timely and adequate treatment (Beckman, et al. 2010). VTE consists of pulmonary embolism and deep vein thrombosis and its 30-day mortality rate is up to 23% (Tagalakis, et al. 2013; Nijekuter, et al. 2007). Because signs and symptoms of VTE are non-specific, timely recognition of VTE is difficult. However, missed VTE diagnosis is common. Two classic studies of necropsies in large hospitals found that 9%-12% had VTE and 84%-91% were undiagnosed at the time of death (Kawinksi, et al. 1989, Bricola, et al. 2013).

The American Society of Hematology published VTE diagnosis guidelines to provide an evidence-based strategy to efficiently evaluate patients (Crawford C, 2019; ASH, 2020.). The goal of these guidelines is to improve diagnostic accuracy by assisting providers with evaluating patients with suspected VTE while reducing unnecessary and more invasive testing (Lim, et al. 2018). While routine use of guidelines in primary care would likely reduce the number of missed or delayed VTE diagnoses, integration into practice is challenging. VTE symptoms are nonspecific and often present as symptoms consistent with an underlying chronic illness. Strategies such as CDS and measurement of diagnostic performance are needed to assist primary care providers with adopting VTE diagnosis guidelines and routinely using them in clinical practice. Currently there is no way to measure VTE diagnostic performance. Metrics are needed to quantify suboptimal VTE diagnostic performance, improved early recognition of VTE symptoms, and ultimately reducing unfavorable VTE outcomes. Measuring and reporting delayed VTE diagnosis rates will inform healthcare providers and facilities about opportunities to improve care, strengthen incentives for quality improvement, and ultimately improve the quality of care received by patients.

Clinical Recommendation Statement

See measure's description.

Improvement Notation

A lower score (expressed as a percentage) is indicative of higher quality care.

Reference

Reference Type: CITATION

Reference Text: 'Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Archives of internal medicine. 2004 Jan 12;164(1):17-26.'

Reference

Reference Type: CITATION

Reference Text: 'Pellathy T, Saul M, Clermont G, Dubrawski AW, Pinsky MR, Hravnak M. Accuracy of identifying hospital acquired venous thromboembolism by administrative coding: implications for big data and machine learning research. Journal of Clinical Monitoring and Computing. 2021 Feb 8:1-9.'

Reference

Reference Type: CITATION

Reference Text: 'Ageno W, Agnelli G, Imberti D, Moia M, Palareti G, Pistelli R, Rossi R, Verso M, MASTER Investigators. Factors associated with the timing of diagnosis of venous thromboembolism: results from the MASTER registry. Thrombosis research. 2008 Jan 1;121(6):751-6.'

Reference

Reference Type: CITATION

Reference Text: 'Dalen JE. Pulmonary embolism: what have we learned since virchow?: natural history, pathophysiology, and diagnosis. Chest. 2002 Oct 1;122(4):1440-56.'

Reference

Reference Type: CITATION

Reference Text: 'Ozsu S, Oztuna F, Bulbul Y, Topbas M, Ozlu T, Kosucu P, Ozsu A. The role of risk factors in delayed diagnosis of pulmonary embolism. The American journal of emergency medicine. 2011 Jan 1;29(1):26-32.'

Reference

Reference Type: CITATION

Reference Text: 'Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, Elstein AS, Hasler S, Kabongo ML, Krosnjar N, Odwazny R, Wisniewski MF, McNutt RA. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009 Nov 9;169(20):1881-7. doi: 10.1001/archinternmed.2009.333. PMID: 19901140.'

Reference

Reference Type: CITATION

Reference Text: 'Chopard R, Albertsen IE, Piazza G. Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA. 2020 Nov 3;324(17):1765-1776. doi: 10.1001/jama.2020.17272. PMID: 33141212.'

Reference

Reference Type: CITATION

Reference Text: 'Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010 Apr;38(4 Suppl):S495-501. doi: 10.1016/j.amepre.2009.12.017. PMID: 20331949.'

Reference

Reference Type: CITATION

Reference Text: 'Uhland H, Goldberg  LM. Pulmonary Embolism: A Commonly Missed Clinical Entity EMBOLISM. Dis Chest. 1964 May;45:533-6. doi: 10.1378/chest.45.5.533. PMID: 14147480'

Reference

Reference Type: CITATION

Reference Text: 'Büller HR, Ten Cate-Hoek AJ, Hoes AW, Joore MA, Moons KG, Oudega R, Prins MH, Stoffers HE, Toll DB, van der Velde EF, van Weert HC; AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) Investigators. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med. 2009 Feb 17;150(4):229-35. PMID: 19221374.'

Reference

Reference Type: CITATION

Reference Text: 'Van Maanen R, Kingma AEC, Oudega R, Rutten FH, Moons K, Geersing GJ. Real-life impact of clinical prediction rules for venous thromboembolism in primary care: a cross-sectional cohort study. BMJ Open. 2020 Dec 28;10(12):e039913. doi: 10.1136/bmjopen-2020-039913. PMID: 33372074; PMCID: PMC7772307.'

Reference

Reference Type: CITATION

Reference Text: 'Fang MC, Fan D, Sung SH, Witt DM, Schmelzer JR, Steinhubl SR, Yale SH, Go AS. Validity of Using Inpatient and Outpatient Administrative Codes to Identify Acute Venous Thromboembolism: The CVRN VTE Study. Med Care. 2017 Dec;55(12):e137-e143. doi: 10.1097/MLR.0000000000000524. PMID: 29135777; PMCID: PMC5125903.'

Reference

Reference Type: CITATION

Reference Text: 'Baumgartner C, Go AS, Fan D, Sung SH, Witt DM, Schmelzer JR, Williams MS, Yale SH, VanWormer JJ, Fang MC. Administrative codes inaccurately identify recurrent venous thromboembolism: The CVRN VTE study. Thromb Res. 2020 May;189:112-118. doi: 10.1016/j.thromres.2020.02.023. Epub 2020 Mar 5. PMID: 32199174; PMCID: PMC7335977.'

Reference

Reference Type: CITATION

Reference Text: 'Alotaibi GS, Wu C, Senthilselvan A, McMurtry MS. The validity of ICD codes coupled with imaging procedure codes for identifying acute venous thromboembolism using administrative data. Vasc Med. 2015 Aug;20(4):364-8. doi: 10.1177/1358863X15573839. Epub 2015 Apr 1. PMID: 25834115.'

Reference

Reference Type: CITATION

Reference Text: 'Righini M, Le Gal G, Bounameaux H. Venous thromboembolism diagnosis: unresolved issues. Thromb Haemost. 2015 Jun;113(6):1184-92. doi: 10.1160/TH14-06-0530. Epub 2014 Dec 11. PMID: 25503584.'

Reference

Reference Type: CITATION

Reference Text: 'Al-Ani F, Shariff S, Siqueira L, Seyam A, Lazo-Langner A. Identifying venous thromboembolism and major bleeding in emergency room discharges using administrative data. Thromb Res. 2015 Dec;136(6):1195-8. doi: 10.1016/j.thromres.2015.10.035. Epub 2015 Oct 29. PMID: 26553020.'

Reference

Reference Type: CITATION

Reference Text: 'Casez P, Labarère J, Sevestre MA, Haddouche M, Courtois X, Mercier S, Lewandowski E, Fauconnier J, François P, Bosson JL. ICD-10 hospital discharge diagnosis codes were sensitive for identifying pulmonary embolism but not deep vein thrombosis. J Clin Epidemiol. 2010 Jul;63(7):790-7. doi: 10.1016/j.jclinepi.2009.09.002. Epub 2009 Dec 2. PMID: 19959332.'

Reference

Reference Type: CITATION

Reference Text: 'Kearon C. Diagnosis of suspected venous thromboembolism. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):397-403. doi: 10.1182/asheducation-2016.1.397. PMID: 27913507; PMCID: PMC6142443.'

Reference

Reference Type: CITATION

Reference Text: 'Monaghan TF, Rahman SN, Agudelo CW, et al. Foundational Statistical Principles in Medical Research: Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value. Medicina (Kaunas). 2021;57(5):503. Published 2021 May 16. doi:10.3390/medicina57050503'

Reference

Reference Type: CITATION

Reference Text: 'Li T, Curtin-Bowen M, Pullman A, Lipsitz S, Syrowatka A, Sainlaire M, Thai T, Businger A, Davis A, Lieberman JR, Blanchfield B, Bates DW, Dykes PC. Testing of a Risk-Standardized Major Bleeding and Venous Thromboembolism Electronic Clinical Quality Measure for Elective Total Hip and/or Knee Arthroplasties. AMIA Annu Symp Proc. 2022 Feb 21;2021:736-743. PMID: 35308961; PMCID: PMC8861692.'

Definition

A Qualified VTE Encounter must meet the following criteria: 
1. Performed by a provider with one of the following specialties:
    • Nurse Practitioner
    • Physician
    • Medical practitioner
    • Technical healthcare occupation
    • Family medicine specialist
    • General practitioner assistant
    • General practitioner principal
    • Associate general practitioner

2. Preceded by an Index PCP visit in which a VTE-related symptom was recorded during the visit: 
    • cough 
    • hypotension 
    • lightheadedness 
    • Shortness of breath 
    • syncope 
    • tachycardia 
    • chest pain 
    • calf pain 
    • leg pain 
    • foot pain 
    • calf numbness 
    • leg numbness 
    • foot numbness 
    • calf tingling 
    • leg tingling 
    • foot tingling 
    • calf redness 
    • leg redness 
    • foot redness 
    • calf swelling 
    • leg swelling 
    • foot swelling 
    • calf tenderness 
    • leg tenderness 
    • foot tenderness 
    • calf warmth 
    • leg warmth 
    • foot warmth
    • hemoptysis 
 
3. a VTE-related imaging scan, ICD billing codes relating to VTE, and therapeutic anticoagulant RxNorm medication orders were placed within the same encounter, within 30 days of the index PCP visit

Guidance

N/A

Transmission Format

TBD

Initial Population

All Qualified VTE Encounters in which the patient was aged 18 or older at the start of the Qualified VTE Encounter.

Denominator

Equals Initial Population.

Denominator Exclusions

• Preceded by a hospice care intervention order within 90 days of the qualifying VTE encounter
• Preceded by a palliative care encounter within 90 days of the qualifying VTE encounter
• Preceded by another qualified VTE encounter within 6 months

Numerator

All Qualified VTE Encounters in which the VTE diagnosis occurs greater than 24 hours following the Index PCP visit (within 30 days).

Numerator Exclusions

None

Denominator Exceptions

None

Supplemental Data Elements

1. Patient Characteristic Payer
2. Patient Characteristic Race
3. Patient Characteristic Sex
4. Patient Characteristic Ethnicity
5. Patient Characteristic Birthdate

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

/***
Includes all Qualified VTE Encounters in which the patient was aged 18 or older at the start of the qualified VTE encounter.
***/
"Qualified VTE Encounters During Measurement Period" QEncounter
  with ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of QEncounter.relevantPeriod ) >= 18

- Denominator
  - "Initial Population"

Denominator Exclusions

/***
Exclude all qualified VTE encounters that were preceded by a hospice intervention order, a palliative care encounter or another qualified VTE encounter within previous 6 months.
***/
"Qualified VTE Encounter Preceded by a Hospice Care Intervention"
  union "Qualified VTE Encounter Preceded by a Palliative Care Encounter"
  union "Other Qualified VTE Encounter Documented within Previous 6 Months"

Numerator

/***
Includes all qualified VTE encounters in which the VTE diagnosis started greater than 24 hours after a qualifying PCP visit.
****/
"Qualifying Delayed VTE Encounter"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Definitions

Anticoagulation Rx

["Medication, Order": "Anticoagulant Medications"] AntiCoagulantMed

Denominator
- - "Initial Population"

Denominator Exclusions

/***
Exclude all qualified VTE encounters that were preceded by a hospice intervention order, a palliative care encounter or another qualified VTE encounter within previous 6 months.
***/
"Qualified VTE Encounter Preceded by a Hospice Care Intervention"
  union "Qualified VTE Encounter Preceded by a Palliative Care Encounter"
  union "Other Qualified VTE Encounter Documented within Previous 6 Months"

Initial Population

/***
Includes all Qualified VTE Encounters in which the patient was aged 18 or older at the start of the qualified VTE encounter.
***/
"Qualified VTE Encounters During Measurement Period" QEncounter
  with ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of QEncounter.relevantPeriod ) >= 18

Numerator

/***
Includes all qualified VTE encounters in which the VTE diagnosis started greater than 24 hours after a qualifying PCP visit.
****/
"Qualifying Delayed VTE Encounter"

Other Qualified VTE Encounter Documented within Previous 6 Months

"Qualified VTE Encounters" PreviousQualifiedVTE
  with "Qualified VTE Encounters" CurrentQualifiedVTE
    such that PreviousQualifiedVTE.relevantPeriod starts 6 months or less before start of CurrentQualifiedVTE.relevantPeriod

Qualified VTE Encounter Preceded by a Hospice Care Intervention

/***
Identify qualified VTE encounters that were preceded by a Hospice care intervention
***/
"Qualified VTE Encounters" VTE
  with ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
    such that HospiceOrder.authorDatetime before start of VTE.relevantPeriod
      and HospiceOrder.authorDatetime during "Measurement Period"

Qualified VTE Encounter Preceded by a Palliative Care Encounter

/***
Identify qualified VTE encounters that were preceded by a palliative care encounter
***/
"Qualified VTE Encounters" VTE
  with ["Encounter, Performed": "Palliative Care Encounter"] PalliativeEncounter
    such that PalliativeEncounter.relevantPeriod starts before start of VTE.relevantPeriod
      and PalliativeEncounter.relevantPeriod overlaps "Measurement Period"

Qualified VTE Encounters

from
  "Qualifying Performed VTE Encounters with Diagnosis Date Started within 30 Days Following the Index PCP Visit" Enc,
  "VTE-Related Imaging Scan" ImagingScan,
  "Anticoagulation Rx" AnticoagulationMed
  where ImagingScan.relevantPeriod ends during Enc.relevantPeriod
    and AnticoagulationMed.authorDatetime during Enc.relevantPeriod
  return Enc

Qualified VTE Encounters During Measurement Period

"Qualified VTE Encounters" VTEEncounter
  where VTEEncounter.relevantPeriod overlaps "Measurement Period"

Qualifying Delayed VTE Encounter

"Qualified VTE Encounters During Measurement Period" VTEEnc
  with "Qualifying Performed PCP Visits with VTE Symptom" IndexPCPVisit
    such that VTEEnc.relevantPeriod starts during Interval[
    end of IndexPCPVisit.relevantPeriod + 24 hours, 
    end of IndexPCPVisit.relevantPeriod + 30 days]

Qualifying Performed Encounters

/***
Identify encounters that were performed by specific provider type (e.g. family medicine, nurse, general practitioner, medical practioner, physician) during specified period (i.e. 180 days before MP and end of MP.  The 180 days period before MP is needed as we need to look back for another qualified VTE encounter.)
***/
( ["Encounter, Performed": "Office Visit"]
  union ["Encounter, Performed": "Outpatient"]
  union ["Encounter, Performed": "Inpatient Encounter"] ) Encounter
  where Encounter.relevantPeriod overlaps Interval[start of "Measurement Period" - 180 days, 
  end of "Measurement Period"]
    and exists ( Encounter.participant Participant
        where Participant.role in "Provider Types"
    )

Qualifying Performed PCP Visits

/***
Identify encounters that were performed by specific provider type (e.g. family medicine, nurse, general practitioner, medical practioner, physician) during specified period (i.e. 211 days before MP and end of MP.  The 211 days period before MP is needed as we need to look back for another qualified VTE encounter.)
***/
( ["Encounter, Performed": "Outpatient"]
  union ["Encounter, Performed": "Office Visit"] ) QualifiedPCP
  where QualifiedPCP.relevantPeriod overlaps Interval[start of "Measurement Period" - 211 days, 
  end of "Measurement Period" )
    and exists ( QualifiedPCP.participant Participant
        where Participant.role in "Provider Types"
    )

Qualifying Performed PCP Visits with VTE Symptom

"Qualifying Performed PCP Visits" PCPVisit
  where exists ( PCPVisit.diagnoses VTESymptom
      where VTESymptom.code in "VTE Symptoms"
  )

Qualifying Performed VTE Encounters

from
  "Qualifying Performed Encounters" Enc,
  "VTE Diagnosis" VTEDiagnosis
  where VTEDiagnosis.prevalencePeriod starts during Enc.relevantPeriod

Qualifying Performed VTE Encounters with Diagnosis Date Started within 30 Days Following the Index PCP Visit

"Qualifying Performed VTE Encounters" VTEEnc
  with "Qualifying Performed PCP Visits with VTE Symptom" IndexPCPVisit
    such that VTEEnc.VTEDiagnosis.prevalencePeriod overlaps Interval[
    end of IndexPCPVisit.relevantPeriod, 
    end of IndexPCPVisit.relevantPeriod + 30 days]
  return VTEEnc.Enc

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

VTE Diagnosis

["Diagnosis": "VTE Diagnoses"] VTEDiagnosis

VTE-Related Imaging Scan

["Diagnostic Study, Performed": "Imaging Related to VTE"] ImagingScan

Functions

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

code "Birth date" ("LOINC Code (21112-8)")
valueset "Anticoagulant Medications" (2.16.840.1.113762.1.4.1206.19)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Hospice Care Ambulatory" (2.16.840.1.113762.1.4.1108.15)
valueset "Imaging Related to VTE" (2.16.840.1.113762.1.4.1206.47)
valueset "Inpatient Encounter" (2.16.840.1.113883.3.117.1.7.1.23)
valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Outpatient" (2.16.840.1.113883.3.464.1003.101.12.1087)
valueset "Palliative Care Encounter" (2.16.840.1.113883.3.464.1003.101.12.1090)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "Provider Types" (2.16.840.1.113762.1.4.1206.53)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "VTE Diagnoses" (2.16.840.1.113762.1.4.1206.49)
valueset "VTE Symptoms" (2.16.840.1.113762.1.4.1206.51)

Data Criteria (QDM Data Elements)

"Diagnosis: VTE Diagnoses" using "VTE Diagnoses (2.16.840.1.113762.1.4.1206.49)"
"Diagnostic Study, Performed: Imaging Related to VTE" using "Imaging Related to VTE (2.16.840.1.113762.1.4.1206.47)"
"Encounter, Performed: Inpatient Encounter" using "Inpatient Encounter (2.16.840.1.113883.3.117.1.7.1.23)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient" using "Outpatient (2.16.840.1.113883.3.464.1003.101.12.1087)"
"Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.464.1003.101.12.1090)"
"Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15)"
"Medication, Order: Anticoagulant Medications" using "Anticoagulant Medications (2.16.840.1.113762.1.4.1206.19)"
"Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set