Half of Flagged VTEs Not Preventable, Study Finds

Beth Skwarecki

July 29, 2015

Some patients develop blood clots despite optimal care, and others are being inadequately treated to prevent clots, according to a study of hospital-acquired venous thromboembolism (VTE) published online July 29 in JAMA Surgery. The researchers argue that financial penalties, such as those levied by the Centers for Medicare & Medicaid Services, unfairly punish hospitals for VTEs that cannot be prevented.

"To reduce preventable harm, policymakers need to re-evaluate how they penalize hospitals and improve the measures they use to assess VTE prevention performance. In addition, clinicians need to ensure that patients receive all prescribed preventive therapies," first author Elliott Haut, MD, PhD, from the Division of Acute Care Surgery at Johns Hopkins University School of Medicine in Baltimore, Maryland, notes in a university news release.

The investigators examined records for the 128 patients who developed VTEs in the Johns Hopkins Hospital between July 2010 and June 2011 and whose cases were flagged by a pay-for-performance initiative. Of those, 36 (28%) were upper-extremity catheter-related DVT, which the researchers judged to be nonpreventable, and were excluded from further analysis.

Of the remaining patients, 45 had DVT only, 43 had a pulmonary embolism only, and four had both.

Of these patients, 43 (47%) received "defect-free" care, which the researchers argue should not be penalized because best care practices were followed.

Among the 49 (53%) patients who received care that was less than ideal, 13 patients were not prescribed risk-appropriate prophylaxis, and 36 missed at least one dose of appropriately prescribed prophylaxis.

The importance of missed doses has been underappreciated, the authors note, and should be the focus of future prevention efforts.

“Our study identifies a need to dramatically reevaluate the VTE outcome and process measures,” the authors write. “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.”

Dr Haut and three coauthors are supported by contracts from the Patient-Centered Outcomes Research Institute. One of these coauthors also 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 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 also is a paid consultant for the "Preventing Avoidable Venous Thromboembolism—Every Patient, Every Time" VHA IMPERATIV Advantage Performance Improvement Collaborative. Another coauthor has given expert witness testimony in various medical malpractice cases. Another coauthor reports receiving honoraria from various healthcare organizations for speaking on quality and patient safety and book royalties from the Penguin Group, as well as stock and fees to serve as a director for Cantel Medical, and 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. The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online July 29, 2015. Abstract


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