Photo courtesy of the CDC
Imposing financial penalties on hospitals based on the incidence of hospital-acquired venous thromboembolism (VTE) may be unfair, according to researchers.
They argue that pay-for-performance systems should take VTE prevention efforts into account, instead of simply tallying the number of hospital-acquired VTEs.
They say the current system fails to account for VTEs that occur despite appropriate use of preventive therapies.
The researchers expressed this viewpoint and disclosed research supporting it in a letter to JAMA Surgery.
“We have a big problem with current pay-for-performance systems based on ‘numbers-only’ total counts of clots, because even when hospitals do everything they can to prevent venous thromboembolism events, they are still being dinged for patients who develop these clots,” said Elliott R. Haut, MD, PhD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland.
“Our study of patients just at The Johns Hopkins Hospital identifies a need to dramatically re-evaluate the venous thromboembolism outcome and process measures. Nearly half of the venous thromboembolism events identified by the state program in the records we reviewed were not truly preventable because patients received best practice prevention and still developed blood clots.”
Dr Haut and his colleagues reviewed case records for 128 patients treated between July 2010 and June 2011 at The Johns Hopkins Hospital and who developed hospital-acquired VTE. All 128 were flagged by the Maryland Hospital Acquired Conditions pay-for-performance program.
The researchers looked for evidence that all of the VTEs could have been prevented. They found that 36 patients (28%) had nonpreventable, catheter-related upper extremity deep vein thrombosis (DVT), leaving 92 patients (72%) with clots that were potentially preventable.
Of those 92 patients, 45 had a DVT, 43 had a pulmonary embolism (PE), and 4 had a DVT and PE.
Seventy-nine of the 92 patients (86%) were prescribed optimal thromboprophylaxis, yet only 43 (47%) received “defect-free care,” the researchers found.
Of the 49 patients (53%) who received suboptimal care, 13 (27%) were not prescribed risk-appropriate anticoagulants, and 36 (73%) missed at least one dose of appropriately prescribed medication.
Dr Haut noted that a team of physicians, nurses, quality care researchers, and pharmacists at Johns Hopkins has been studying VTE prevention for the past decade.
Team members have implemented programs to monitor patients in need of VTE prophylaxis through the hospital’s electronic health record system, and they conducted special training for nurses and patients to stress the importance of taking every dose of prescribed medication.
“We know we’re not going to get the VTE rate to 0, but my goal is to have every single one of these events—when they happen—occur when the patient receives best-practice, defect-free care,” Dr Haut said.
The current VTE care goal set by agencies like the Joint Commission and the Centers for Medicare and Medicaid Services is that one dose of VTE prophylaxis is given to patients within the first day of hospitalization. But Dr Haut said this is not enough.
“To reduce preventable harm, policymakers need to re-evaluate how they penalize hospitals and improve the measures they use to assess VTE prevention performance,” he said. “In addition, clinicians need to ensure that patients receive all prescribed preventive therapies.”
