VTE Not a Reliable Quality Measure of Hospital Performance

Yael Waknine

June 12, 2015

A new prospective study adds to mounting evidence against the validity of postsurgical venous thromboembolism (VTE) rates as an indicator of hospital performance quality.

The analysis, published online July 10 in JAMA Surgery, included 16,120 patients undergoing colorectal operations at 52 Washington State Surgical Care and Outcomes Assessment Program (SCOAP) hospitals between January 1, 2006, and December 31, 2011.

The researchers found that although use of perioperative and in-hospital VTE prophylaxis increased from 31.6% and 59.6% to 86.4% and 91.4%, respectively, the incidence of 90-day VTE remained stable at 2.2%, after adjusting for patient and operative variables.

"Unfortunately, this study cannot explain why VTE rates remain unchanged. One possibility is that the national focus on VTE prevention as a quality measure and reimbursement driver may result in increased surveillance and closer monitoring of patients receiving prophylaxis. Therefore, the increased VTE incidence may reflect increased identification of clinically silent VTE," write Scott R. Steele, MD, from the Department of Surgery at Madigan Army Medical Center in Tacoma, Washington, and colleagues from the SCOAP–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative.

Abdominal operations were associated with higher 90-day VTE rates than pelvic surgeries (2.5% vs 1.8%; P = .001), but there was no difference associated with procedures for cancerous vs noncancerous conditions (2.1% vs 2.3%; P = .24). As expected, factors for VTE included older age, nonelective surgery, history of VTE, and operations for inflammatory disease (P < .05 for all).

"[P]revention of VTE is high on the radar of all US hospitals," write Christian de Virgilio, MD, and Jerry J. Kim, MD, from the Department of Surgery at Harbor-University of California, Los Angeles, Medical Center in Torrance, in an associated commentary.

The controversial quality-of-care measure is a key factor in determining facility eligibility for the 1% reduction to Medicare payments offered by the Hospital Acquired Condition reduction program in 2015, as mandated by the Patient Protection and Affordable Care Act.

"Despite this increased focus on VTE, emerging data suggest that VTE rates may be a poor indicator of hospital quality and that more prophylaxis is not necessarily better," they add. Supporting their point of view, they cite another recent study showing that high VTE rates may reflect a surveillance bias, rather than poor quality of care.

Linking VTE rates with financial incentives may prompt clinicians to avoid imaging procedures when the indications are questionable, and use of extended prophylaxis could cause bleeding complications, Dr de Virgilio and Dr Kim point out.

"In an era where quality measures and outcomes are increasingly being linked to reimbursement and economic burden, thoughtful consideration should be given to ensure that truly modifiable and well-understood outcomes are the driving force for health policy," they conclude.

The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. The authors and commenters have disclosed no relevant financial relationships. The study previously was presented February 20, 2015, at the 86th Annual Meeting of the Pacific Coast Surgical Association in Monterey, California.

JAMA Surg. Published online June 10, 2015. Article full text, Commentary extract


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