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Why Post-Operative VTE Might Not Be an Accurate Hospital Quality Indicator

TACOMA, WA –Postoperative venous thromboembolism (VTE) is one of the most heavily weighted indicators in the Centers for Medicare & Medicaid Services’ Hospital Acquired Condition (HAC) Reduction Program, which can affect reimbursement for hospitals that fail to meet specified quality indicators.

The problem, according to a recent study and related commentary published by JAMA Surgery, is that VTE may be a poor indicator for hospital quality.

Scott R. Steele, MD, from Madigan Army Medical Center in Tacoma and colleagues from the SCOAP-Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative sought to describe the incidence and risk of VTE as well as current prophylaxis patterns following colorectal surgery that seek to prevent the condition.

The study, which used prospective data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP) linked to a statewide hospital discharge database, focused on consecutive patients at 52 Washington State SCOAP hospitals undergoing colorectal surgery from 2006 to 2011.

The study looked at VTE complications in the hospital and as many as 90 days after surgery.

VTE chemoprophylaxis use increased significantly, both perioperatively and during hospital care, from 31.6% to 86.4% and from 59.6% to 91.4%, respectively, by 2011. Yet, no significant decrease in VTE was detected over time, according to the study.

"Unfortunately, this study cannot explain why VTE rates remain unchanged,” the authors write. “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.”

A related commentary from Christian de Virgilio, MD, and Jerry J. Kim, MD, from Harbor-University of California, Los Angeles, Medical Center in Torrance, was less charitable.

"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," de Virgilio and Kim write, citing another study which recently indicated that high VTE rates might reflect surveillance bias, not poor care.

The commentators suggest that linking VTE rates and financial incentives could negatively affect clinical practice. Clinicians might avoid imaging procedures when the indications are questionable or downplay bleeding complications of extended prophylaxis, they point out, concluding, "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.”