Prevention of Venous Thromboembolism Surgical Care Improvement Project

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Prevention of Venous ThromboembolismSurgical
Care Improvement Project
Dale W. Bratzler, DO, MPH President and
CEO Oklahoma Foundation for Medical Quality
Dale W. Bratzler, DO, MPH QIOSC Medical Director
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Why is there a need to measure the quality of
hospital care?

• The passive strategy of guideline publication and
  dissemination does not effectively change
  clinical practice
• The time lag between publication of evidence and
  incorporation into care at the bedside is very
  long
• Variations in care and delivery of care that is
  not consistent with evidence-based
  recommendations is well documented

Bratzler DW. Development of national performance
measures on the prevention and treatment of
venous thromboembolism. J Thromb Thrombolysis.
2009 (in press)
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Prevention of Venous Thromboembolism (VTE) an
example

• The American College of Chest Physicians
  published their first consensus conference on
  antithrombotic therapy in 1986
• In 2008 published their 8th edition of the
  evidence-based guideline
• Despite all of these published editions..

VTE - the most common preventable cause of
hospital death - 2/3 of all cases occur in
recently hospitalized patients - up to 3/4 of
all cases of PE death are a result of
hospitalization
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Prevention of Venous Thromboembolism an example

• Multiple studies that have included hospital
  medical record audits show consistent underuse of
  VTE prophylaxis
• Up to 2/3 of patients with hospital-acquired VTE
  did not receive prophylaxis
• Audits of patients receiving treatment for
  confirmed VTE show non-compliance with
  guideline-recommended treatment

Bratzler DW. Development of national performance
measures on the prevention and treatment of
venous thromboembolism. J Thromb Thrombolysis.
2009 (in press)
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• The best estimates indicate that 350,000 to
  600,000 Americans each year suffer from DVT and
  PE, and that at least 100,000 deaths may be
  directly or indirectly related to these diseases.
  This is far too many, since many of these deaths
  can be avoided. Because the disease
  disproportionately affects older Americans, we
  can expect more suffering and more deaths in the
  future as our population agesunless we do
  something about it.

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Risk Factors for DVT or PENested Case-Control
Study (n625 case-control pairs)
Surgery Trauma Inpatient Malignancy with
chemotherapy Malignancy without
chemotherapy Central venous catheter or
pacemaker Neurologic disease Superficial vein
thrombosis Varicose veins/age 45 yr Varicose
veins/age 60 yr Varicose veins/age 70 yr CHF, VTE
incidental on autopsy CHF, antemortem VTE/causal
for death Liver disease
0
5
10
15
20
25
50
Odds ratio
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Risk Factors for VTE
Most hospitalized patients have at least one
additional risk factor for VTE

• Surgery
• Trauma
• Immobility, paresis
• Malignancy
• Cancer therapy
• hormonal therapy, chemotherapy or radiotherapy
• Previous VTE
• Increasing age
• Pregnancy and post-partum period
• Estrogen-containing oral contraception or HRT or
  SERM

• Acute medical illness
• Heart failure
• Respiratory failure
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Obesity
• Smoking
• Varicose veins
• Central venous catheterization
• Inherited or acquired thrombophilia
• Travel

Geerts W et al. Chest. 2004126338S-400S.
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VTE Facts

• Almost half of the outpatients with VTE had been
  recently hospitalized
• Less than half of the recently hospitalized
  patients had received VTE prophylaxis during
  their hospitalizations
• About half had a length of stay (LOS) of lt 4 days

Days After Discharge
0-29
30-59
60-90
70
60
50
40
Outpatients With VTE,
30
20
10
0
Hospitalization with Surgery
Medical Hospitalization Only
Goldhaber S. Arch Intern Med. 20071671451-2. Spe
ncer FA et al. Arch Intern Med.
2007167(14)1471-5.
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Categories of Risk for Venous Thromboembolism in
Patients

• Low risk
• Minor surgery in mobile patients
• Moderate risk
• Most medically ill, general, open gyn or
  urologic surgery patients
• High risk
• Cancer surgery, hip or knee arthroplasty, hip
  fracture surgery, major trauma or spinal cord
  injury

Geerts W et al. Chest. 2008133381S-453S.
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Mechanical Methods of VTE Prevention

• Graduated Compression Stockings (GCS)
• Intermittent Pneumatic Compression Devices (IPCs)
• Venous Foot Pump (VFP)

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Pharmacologic Options for VTE Prevention

• Unfractionated Heparin (UFH)
• Low-Molecular Weight Heparins (LMWHs)
• Pentasaccharide (Fondaparinux)
• Warfarin

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Prophylaxis Against Fatal Post-Operative PE With
LDUH A Multicenter, Prospective, Randomized
Trial

• Study population 4,121 patients age gt 40 y
  undergoing a variety of elective major surgical
  procedures

P lt 0.005
0.9
0.77
0.8
0.7
0.6
0.5
Patients with PE ()
0.4
0.3
0.2
0.097
0.1
0
Control (N 2,076)
UFH (N 2,045)

• 5,000 IU SC 2 hours preoperatively and 8 hours
  thereafter for 7 days.

Kakkar VV et al. Lancet. 1975245-51.
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Mechanical Thromboprophylaxis

• For particularly high-risk surgery patients with
  multiple risk factors, pharmacologic method
  should be combined with mechanical method (GCS,
  IPC) (1C)
• Use mechanical methods for patients with high
  bleeding risk (1A), when bleeding risk decreases
  substitute or add pharmacological
  thromboprophylaxis (1C)

Geerts WH et al. Chest. 2008133(6
Suppl)381S-453S.
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Problems with Mechanical Prophylaxis

• Non-compliance
• 50 of med-surg floors
• 80 in intensive care units
• Most common reasons for non-compliance
• 80 of the time, not on the patient
• 20 of the time, on the patient but not turned on

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VTE ProphylaxisGrade 1 Recommendations
Limited to those patients who have an anesthesia
duration of at least 60 minutes, and a hospital
stay of at least three calendar days (two nights
in the hospital).
Open surgical procedure gt 30 minutes requiring
in-hospital stay gt 24 hours postoperative.
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VTE ProphylaxisGrade 1 Recommendations
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VTE ProphylaxisGrade 1 Recommendations
Open surgical procedure gt 30 minutes requiring
in-hospital stay gt 24 hours postoperative.
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Performance Measurement Does Not Happen without
Controversy
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What else does the AAOS guideline say?

• They do NOT recommend the use of aspirin alone
• They recommend the use of mechanical prophylaxis
  started in the operating room or immediately
  postoperatively in all patients continued to
  discharge
• They recommend pharmacologic prophylaxis with
  LMWH, factor Xa inhibitor, or warfarin in high
  risk patients
• previous history of cancer, thromboembolism,
  hypercoagulable states such as polycythemia,
  spinal cord injury patients, multi-trauma
  patients, and genetic predisposition

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VTE Prophylaxis

• Other issues
• Timing of prophylaxis
• Neuraxial anesthesia
• Renal insufficiency
• Duration of prophylaxis

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Venous ThromboembolismStatement of Organization
Policy

• Every healthcare facility shall have a written
  policy appropriate for its scope, that is
  evidence-based and that drives continuous quality
  improvement related to VTE risk assessment,
  prophylaxis, diagnosis, and treatment.

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Measure specifications available at
www.qualitynet.org
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Electronic Submission of Performance Measures

• In the recently published final IPPS rule for
  fiscal year 2010, CMS has announced that through
  an interagency agreement with the Office of the
  National Coordinator for Healthcare Information
  Technology, they are developing interoperable
  standards for electronic medical record
  submission of the newly-endorsed VTE measures.
  Vendors of electronic medical record systems
  would be able to code their systems with the new
  specifications by the end of 2009.

Centers for Medicare Medicaid Services.
Medicare Program Changes to the Hospital
Inpatient Prospective Payment Systems for Acute
Care Hospitals and Fiscal Year 2010 Rates and
Changes to the Long-Term Care Hospital
Prospective Payment System and Rate Years 2010
and 2009 Rates. Available at http//www.federalre
gister.gov/OFRUpload/OFRData/2009-18663_PI.pdf.
Accessed 10 August 2009.
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Improving Use of VTE Prophylaxis
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Strategies to Improve VTE Prophylaxis

• Hospital policy of risk assessment or routine
  prophylaxis for all admitted patients
• Most will have risk factors for VTE and should
  receive prophylaxis
• Preprinted protocols for surgical patients

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Electronic Alerts to Prevent VTE among
Hospitalized Patients

• Hospital computer system identified patient VTE
  risk factors
• RCT no physician alert vs physician alert

Control Alert group group
P No. 1,251 1,255 Any prophylaxis
15 34 lt0.001 VTE at 90 days
8.2 4.9 0.001 Major bleeding
1.5 1.5 NS
NNT 30
Kucher NEJM 2005352969
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Improving Compliance with Treatment Protocols

• Use of standardized protocols, nomograms,
  algorithms, or preprinted orders
• Address overlap (either 5 days in hospital or
  discharge on overlap)
• When used, UFH should be managed by
  nomogram/protocol, and the protocol should ensure
  routine platelet count monitoring

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Essential Elements for Improvement

• Institutional support
• A multidisciplinary team or steering committee
• Reliable data collection and performance tracking
  
• Specific goals or aims
• A proven QI framework
• Protocols

SHM Resource Room. http//www.hospitalmedicine.org
. Accessed September 2009.
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Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
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Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
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Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
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Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
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Attention to Transitions of Care

• Ensure adequate training of the patient
• Education on medications, diet, follow up
  appointments, lab monitoring, dietary
  precautions, and adverse reactions or drug-drug
  interactions
• Education for family
• Referral to anticoagulation clinic
• Hospital abstractors must find explicit
  documentation of this training/education in the
  chart

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Does public reporting accelerate quality
improvement?
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Changes in National Performance Baseline to Q1,
2009
//
National sample of 19,497 Medicare patients
undergoing surgery in US hospitals during the
first quarter of 2005. (Bratzler, unpublished data
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Hospital-acquired ConditionsBackground of the
Never Events

• Deficit Reduction Act (DRA) of 2005 requires the
  Secretary of HHS to identify conditions that are
• High cost or high volume (or both) and
• Result in the assignment of a case to a DRG that
  has a higher payment when present as a secondary
  diagnosis and
• Could reasonably have been prevented through the
  application of evidence-based guidelines.

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Hospital-acquired Conditions

• Deep vein thrombosis/pulmonary embolism
  following
• Total knee replacement
• Hip replacement

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Conclusions

• VTE remains a substantial health problem in the
  US
• VTE prophylaxis remains underutilized
• National performance measures will address both
  prophylaxis and treatment of VTE across broad
  hospital populations

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dbratzler_at_ofmq.com