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Research Letter |

Preventability of Hospital-Acquired Venous Thromboembolism FREE

Elliott R. Haut, MD, PhD1,2,3,4,5; Brandyn D. Lau, MPH, CPH1,4,5,6; Peggy S. Kraus, PharmD7; Deborah B. Hobson, BSN5; Bhunesh Maheshwari, MBBS8; Peter J. Pronovost, MD, PhD2,4,5; Michael B. Streiff, MD5,8,9
[+] Author Affiliations
1Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
3Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
4Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
5Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
6Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
7Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
8Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
9Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Surg. 2015;150(9):912-915. doi:10.1001/jamasurg.2015.1340.
Text Size: A A A
Published online

Venous thromboembolism (VTE) is a common, largely preventable condition. The Agency for Healthcare Research and Quality reports that VTE prophylaxis is among the top-10 strongly suggested practices for improving patient safety.1 Although optimal VTE prevention requires both prescription and administration of prophylactic medications, to date, most attempts to improve care have focused predominantly on medication prescription.2

National bodies (eg, the Centers for Medicare and Medicaid Services) and regional entities (eg, the Maryland Health Services Cost Review Commission) impose financial penalties for hospitalized patients developing VTE despite evidence that not all events are preventable, even with prophylaxis.3 Publicly reported measures from both The Joint Commission’s Core Measures and the Centers for Medicare and Medicaid Services’ Hospital Compare report whether a patient received at least 1 dose of VTE prophylaxis within the first day of hospitalization, rather than considering all prescribed and administered doses for the entire hospitalization.4

Current measures for the quality of VTE care provide limited insights into the extent to which VTE is preventable. The specific aim of our study was to characterize the true preventability of VTE by identifying the proportion of patients with VTE who had received “defect-free care.”

We conducted a retrospective review of patients with hospital-acquired VTE identified by the Maryland Hospital Acquired Conditions pay-for-performance initiative at the Johns Hopkins Hospital for 1 year (July 2010–June 2011). Our study was approved by the institutional review board of the Johns Hopkins University School of Medicine under a waiver of consent. Data on patient risk assessment for VTE (using our mandatory computerized clinical decision support tool), prescription of risk-appropriate prophylaxis,5 and pharmacological prophylaxis administration were abstracted from the electronic health record.

Because catheter-associated deep vein thrombosis (DVT) is not preventable with prophylaxis,6 we excluded patients with upper extremity, catheter-associated DVT. The remaining patients were dichotomized by whether or not they received defect-free care, which is defined as receiving all doses of risk-appropriate VTE prophylaxis as recommended by our validated, mandatory computerized clinical decision support tool5 prior to VTE diagnosis. Suboptimal care was further classified as prescription failures or dose-administration failures. We counted patients with a documented contraindication to pharmacologic prophylaxis (n = 6) who were prescribed sequential compression devices as defect-free care. We compared characteristics between groups using a 2-sided χ2 test, an unpaired t test, or the Wilcoxon rank sum test using Stata version 12.0 (StataCorp).

A total of 128 patients had hospital-acquired VTE. Of these 128 patients, 36 (28%) had nonpreventable, catheter-related DVT, leaving 92 patients (72%) who experienced VTE events (45 had DVT only, 43 had a pulmonary embolism only, and 4 had both DVT and a pulmonary embolism) that were potentially preventable with prophylaxis (Table). Of the 92 patients who experienced VTE events, 79 (86%) were prescribed optimal prophylaxis, yet only 43 (47%) received defect-free care. Of the 49 patients (53%) who received suboptimal care, 13 (27%) were not prescribed risk-appropriate VTE prophylaxis, and 36 (73%) missed at least 1 dose of appropriately prescribed prophylaxis (Figure). There was no difference in suboptimal care patterns between surgical and medical patients.

Table Graphic Jump LocationTable.  Demographic and Clinical Characteristics of Patients Developing Preventable VTEa
Place holder to copy figure label and caption
Figure.
Categorization of Patients With Hospital-Acquired VTE by Process of Care Appropriateness

Of the 92 patients with a venous thromboembolism (VTE), 43 (47%) received defect-free care, while 49 (53%) had truly potentially preventable VTE and were in the prophylaxis-failure group (ie, 13 of 92 patients were prescribed suboptimal prophylaxis [14%], and 36 of 92 patients missed ≥1 dose of prescribed prophylaxis [39%]).

Graphic Jump Location

Our study identifies a need to dramatically reevaluate the VTE outcome and process measures. Half of VTE events identified in a state-run pay-for-performance program were not truly preventable because patients received best-practice prevention, and there was no real opportunity for improvement. Venous thromboembolism outcome measures should not include these patients as having “potentially preventable events.”

The overwhelming cause (73%) of inadequate VTE prophylaxis was patients missing at least 1 medication dose, which is associated with VTE events.7 Until recently, the importance of missed VTE prophylaxis doses has been underappreciated. Perhaps targeting missed doses will have a significant effect on VTE events.

The current The Joint Commission/Centers for Medicare and Medicaid Services sampling method was likely adopted to reduce the burden of data collection. Our study questions the validity of this approach, which misclassifies suboptimal care as high-quality care, misinforms the public, and may limit efforts by health care professionals to improve VTE prevention when they already score well on these misleading measures. To reduce preventable harm, policy makers need to improve the measures, and clinicians need to ensure that patients receive all prescribed preventative therapies.8 As electronic health records are adopted nationally, information technology will allow us to use more advanced clinical analytics to base VTE process measures on every dose of VTE prophylaxis for every hospitalized patient.

Corresponding Author: Elliott R. Haut, MD, PhD, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed 6107C, Baltimore, MD 21287 (ehaut1@jhmi.edu).

Published Online: July 29, 2015. doi:10.1001/jamasurg.2015.1340.

Author Contributions: Dr Haut and Mr Lau had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Haut, Lau, Kraus, Maheshwari, Streiff.

Acquisition, analysis, or interpretation of data: Haut, Lau, Kraus, Hobson, Maheshwari, Streiff.

Drafting of the manuscript: Haut, Lau, Kraus, Maheshwari, Pronovost, Streiff.

Critical revision of the manuscript for important intellectual content: Haut, Kraus, Hobson, Maheshwari, Pronovost, Streiff.

Statistical analysis: Lau, Maheshwari.

Administrative, technical, or material support: Haut, Lau, Kraus, Streiff.

Study supervision: Haut, Kraus, Streiff.

Conflict of Interest Disclosures: Drs Haut, Streiff, and Pronovost and Mr Lau are supported by a contract from the Patient-Centered Outcomes Research Institute (CE-12-11-4489) entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Mr Lau is supported by a contract (AD-1306-03980) from the Patient-Centered Outcomes Research Institute entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department.” Dr Streiff has received research funding from Bristol-Myers Squibb and honoraria for CME lectures from Sanofi; has consulted for Sanofi, Eisai, Daiichi-Sankyo, Boehringer Ingelheim, and Janssen HealthCare; and has given expert witness testimony in various medical malpractice cases. Dr Haut was the primary investigator of a Mentored Clinician Scientist Development Award (K08 1K08HS017952-01) from the Agency for Healthcare Research and Quality entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” Dr Haut receives royalties from Lippincott, Williams, & Wilkins for the book Avoiding Common ICU Errors and has given expert witness testimony in various medical malpractice cases. Dr Haut is a paid consultant for the “Preventing Avoidable Venous Thromboembolism—Every Patient, Every Time” VHA IMPERATIV Advantage Performance Improvement Collaborative. Ms Hobson has given expert witness testimony in various medical malpractice cases. Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the Gordon and Betty Moore Foundation (research related to patient safety and quality of care), the National Institutes of Health (acute lung injury research), and the American Medical Association (research related to improving blood pressure control); honoraria from various health care organizations for speaking on quality and patient safety (the Leigh Bureau manages these engagements); book royalties from the Penguin Group; and stock and fees to serve as a director for Cantel Medical. Dr Pronovost is a founder of Patient Doctor Technologies, a startup company that seeks to enhance the partnership between patients and clinicians with an application called Doctella. No other disclosures are reported.

Shekelle  PG, Pronovost  PJ, Wachter  RM,  et al.  The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5, pt 2):365-368.
PubMed   |  Link to Article
Lau  BD, Haut  ER.  Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014;23(3):187-195.
PubMed   |  Link to Article
Streiff  MB, Haut  ER.  The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301(10):1063-1065.
PubMed   |  Link to Article
Johnbull  EA, Lau  BD, Schneider  EB, Streiff  MB, Haut  ER.  No association between hospital-reported perioperative venous thromboembolism prophylaxis and outcome rates in publicly reported data. JAMA Surg. 2014;149(4):400-401.
PubMed   |  Link to Article
Streiff  MB, Carolan  HT, Hobson  DB,  et al.  Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative. BMJ. 2012;344:e3935.
PubMed   |  Link to Article
Lau  BD, Haut  ER, Hobson  DB,  et al.  ICD-9 code–based venous thromboembolism (VTE) targets fail to measure up [published online April 21, 2015]. Am J Med Qual. doi:10.1177/1062860615583547.
Louis  SG, Sato  M, Geraci  T,  et al.  Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149(4):365-370.
PubMed   |  Link to Article
Haut  ER, Pronovost  PJ.  Surveillance bias in outcomes reporting. JAMA. 2011;305(23):2462-2463.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Categorization of Patients With Hospital-Acquired VTE by Process of Care Appropriateness

Of the 92 patients with a venous thromboembolism (VTE), 43 (47%) received defect-free care, while 49 (53%) had truly potentially preventable VTE and were in the prophylaxis-failure group (ie, 13 of 92 patients were prescribed suboptimal prophylaxis [14%], and 36 of 92 patients missed ≥1 dose of prescribed prophylaxis [39%]).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Demographic and Clinical Characteristics of Patients Developing Preventable VTEa

References

Shekelle  PG, Pronovost  PJ, Wachter  RM,  et al.  The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5, pt 2):365-368.
PubMed   |  Link to Article
Lau  BD, Haut  ER.  Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014;23(3):187-195.
PubMed   |  Link to Article
Streiff  MB, Haut  ER.  The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301(10):1063-1065.
PubMed   |  Link to Article
Johnbull  EA, Lau  BD, Schneider  EB, Streiff  MB, Haut  ER.  No association between hospital-reported perioperative venous thromboembolism prophylaxis and outcome rates in publicly reported data. JAMA Surg. 2014;149(4):400-401.
PubMed   |  Link to Article
Streiff  MB, Carolan  HT, Hobson  DB,  et al.  Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative. BMJ. 2012;344:e3935.
PubMed   |  Link to Article
Lau  BD, Haut  ER, Hobson  DB,  et al.  ICD-9 code–based venous thromboembolism (VTE) targets fail to measure up [published online April 21, 2015]. Am J Med Qual. doi:10.1177/1062860615583547.
Louis  SG, Sato  M, Geraci  T,  et al.  Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149(4):365-370.
PubMed   |  Link to Article
Haut  ER, Pronovost  PJ.  Surveillance bias in outcomes reporting. JAMA. 2011;305(23):2462-2463.
PubMed   |  Link to Article

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