As venous thromboembolism (VTE) became an increasingly recognized cause of death in hospitalized patients, prevention became a high priority for the health care system.1,2 Starting in 2005, the Joint Commission and the National Quality Forum collaborated to set the stage for the first iteration of VTE-specific measures.3 Since then, numerous other organizations adopted requirements and practices to report VTE prevention measures and outcomes, including the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and other domestic and international accreditation agencies. Today, VTE prophylaxis is a common metric used by many hospitals and hospitalist groups to measure quality and performance.
Case
Mrs. Jones is a 75-year-old woman admitted to the hospital with right lower extremity cellulitis and an abscess that has worsened despite taking oral antibiotics at home. She has a history of well-controlled diabetes, hypertension, and hyperlipidemia. The patient is admitted to the hospital for IV antibiotics and surgical evaluation for possible incision and drainage. She ambulates from the bathroom to the bed. As you decide whether to prescribe VTE prophylaxis, the following thoughts come to mind:
- How can I bypass the continuous electronic health record (EHR) alerts for mandatory VTE prophylaxis?
- Which practitioner is responsible for prophylaxis during the periprocedural period?
- Will I get my bonus if I don’t order the “right” VTE prophylaxis for this patient?
Moving from universal prophylaxis to universal risk assessment
The expanded use of VTE prophylaxis as a quality metric may not have had the intended effects on practice and patient outcomes. Organizational and regulatory pressures to achieve compliance with VTE measures have resulted in blunt applications of these measures, possibly leading to both unnecessary use in some cases and undertreatment in others. Recently, there has been an effort to shift the paradigm from the focus on VTE prophylaxis administration, as is exemplified by the VTE-1 measure, to VTE risk assessment, as is used in both British and Australian quality measures. In simplified terms, the standard is shifting from being an “opt-out” strategy for prophylaxis, to “opt-in” only for high-risk patients.
EHR integration
Across the country, hospitalists are familiar with the “hard stop” for VTE prophylaxis in most EHRs. These embedded clinical decision tools are built around the current, common paradigm of universal prophylaxis for patients, and they ensure regulatory measures are met. In patients for whom the clinical gestalt of the hospitalist says VTE prophylaxis is unnecessary or, worse, potentially harmful, these EHR prompts are cumbersome and disruptive of clinical workflows. Focusing on appropriate risk assessment will increase the likelihood of the right patients getting prophylaxis. However, this shift puts more work on the clinician.
The decision for VTE prophylaxis is no longer a simple review of contraindications but often requires a nuanced understanding of complex risk-assessment tools. This increased mental load could be offset through the optimization of support within the EHR. While varying levels of support and customization can be a limitation with all EHRs, they can still be used as a tool in VTE risk assessment. This can be as simple as displaying the risk-assessment tool and annotating potential orders with the related score ranges, to much more complex systems that can integrate information from the EHR, such as weight and renal function, and present the optimal prophylaxis choice. The feasibility of this approach has been clearly demonstrated.4-6 More work is required to reach this optimal state in most EHRs and will depend on the preferred risk-stratification tool and comfort levels with complete automatization of the process.
Implications of co-management
The role of the hospitalist in surgical co-management and perioperative optimization creates another challenge for measuring VTE prophylaxis. The importance of VTE prevention in the surgical population is emphasized by Patient Safety Indicator (PSI) 12: Perioperative PE or DVT Rate and the impact it has on multiple quality metrics and reimbursement. Unlike those for medical patients, VTE prophylaxis recommendations and supportive literature range widely for surgical patients, depending on the procedure.
As hospitalists work with surgeons to weigh the risk of clotting against bleeding, there may be situations where the two recommendations do not align. When hospitalists serve as consultants, they offer just a recommendation to the primary team, but in co-management arrangements, both parties have a strong responsibility for the patient, and conflicting care plans may emerge. This emphasizes the importance of directed and standardized communication with the surgical team regarding VTE prophylaxis to ensure the appropriate information is being consistently conveyed.
Attribution
These concerns circle back to the initial quandary of using VTE prophylaxis as a quality metric to evaluate hospitalists. The opportunities to measure the process and outcomes of VTE prophylaxis, from risk assessment to actually developing a clinical VTE, present a wide range of attributions, which can be strongly or weakly associated with hospitalists, along with a potential for misattribution.
Some countries use risk assessment as a quality measure, which could minimize attribution bias. However, if measurement is based on the completion of the risk assessment or its accuracy, this would require secondary reviews and could introduce other biases. As another example, the actual administration of appropriate VTE prophylaxis depends not only on the ordering clinician but also on the bedside nurse delivering the medication and the patient’s consent to treatment.
Co-management arrangements also add complexity to attributing performance to a single practitioner. Therefore, the assessment of VTE prophylaxis and even the ultimate outcome measure of clinically significant in-hospital VTE depend on numerous clinical and non-clinical factors, only a few of which fall under the hospitalists’ direct control, making them difficult to apply at the provider level.
Guidance for hospitalist groups
In VTE prophylaxis, there is likely not one single right answer for what process or outcome measure(s) to use for hospitalists, but it is important to understand a measure’s strengths, limitations, and what other factors affect it. As an organization and/or hospitalist group aims to use VTE prophylaxis as a quality process measure, it is also important to understand the new paradigm shift toward risk assessment and to recognize where in the wide continuum of VTE prophylaxis hospitalists can be best attributed and demonstrate the highest impact. Decisions around VTE prophylaxis can be further complicated for hospitalists as their roles expand in the surgical co-management and perioperative optimization settings. To support this process, optimizing the EHR to assist providers in making accurate decisions is key. All these components confound how and if to use VTE prophylaxis as a meaningful quality metric. Overall, if this specific metric is deemed to be a meaningful measure of performance, resources from the organization should be allocated toward optimizing the EHR to assist providers in making accurate decisions. The generation of co-management agreements or rules of engagement among consulting services may also prove helpful. While in-hospital VTEs are clinically significant events for the patient, a cautious and thoughtful approach should be utilized with VTE prophylaxis as a measure for hospitalists.
Dr. Cerasale
Dr. Bruti
Dr. Mandal
Dr. Cerasale is the outcomes quality director for UChicago Medicine, quality improvement director for the section of hospital medicine, and a core faculty member of internal medicine residency at the University of Chicago. Dr. Bruti is the chief of the division of hospital medicine in internal medicine, and the med-peds program director at Rush University Medical Center in Chicago. Dr. Mandal is a med-peds hospitalist in Southern California, whose practice encompasses both community and rural settings. SHM’s Performance Measurement and Reporting Committee periodically contributes articles demystifying performance measures for health care professionals.
Additional resource: See the companion table prepared by members of SHM’s Performance Measurement and Reporting Committee for additional information about this measure.
References
- Heit JA, O’Fallon W, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002;162(11):1245-8.
- Heit JA, Silverstein MD, et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160(6):809-15.
- National Quality Forum. National voluntary consensus standards for prevention and care of venous thromboembolism: policy, preferred practices, and initial performance measures. A consensus report. Washington, D.C.: National Quality Forum; c2006. NLM ID 101477302.
- Darzi AJ, et al. Risk models for VTE and bleeding in medical inpatients: systematic identification and expert assessment. Blood Adv. 2020;4(12):2557-66.
- Spyropoulos, A, et al. Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial. JACC Adv. 2023;2:(8). doi.org/10.1016/j.jacadv.2023.100597
- Haller MD, et al. Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach. J Hosp Med. 2023;18(6):502-8.