Multi-institutional Evaluation of Adherence to Comprehensive Postoperative Venous Thromboembolism Chemoprophylaxis
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1 Multi-institutional Evaluation of Adherence to Comprehensive Postoperative Venous Thromboembolism Chemoprophylaxis D. Brock Hewitt MD MPH, Eddie Blay Jr MD, Lindsey J Kreutzer MPH, Thomas E Kmiecik PhD, Karl Y Bilimoria MD MS FACS, Anthony D Yang MD MS FACS Illinois Surgical Quality Improvement Collaborative
2 Disclosures Supported by grant funding from American College of Surgeons (Thomas R. Russell Faculty Research Fellowship [Yang]), AHRQ (5T32HS [Hewitt]), Health Care Services Corporation/Blue Cross Blue Shield of Illinois
3 VTE = Leading Cause of Preventable Hospital Death in the United States CDC: Death and Statistics on HA-VTE
4 Current Measures Inadequately Capture Comprehensive VTE Chemoprophylaxis Adherence Current outcome measures Surveillance bias 1,2 - The more you look, the more you find Current process measure: SCIP-VTE-2 Only in the 24 hrs before and after surgery 3 Near 100% adherence to measure at the majority of hospitals
5 Novel ISQIC Process Measure Comprehensive post op VTE chemoprophylaxis 4 Ordered Appropriate dose Appropriate frequency Delivered throughout patient s entire inpatient hospitalization
6 Objectives 1. Identify reasons for VTE chemoprophylaxis failure 2. Identify hospital- and patient-level factors associated with VTE chemoprophylaxis failure
7 Evaluation of Collaborative-wide Quality Improvement Project Illinois Surgical Quality Improvement Collaborative (ISQIC) ISQIC Data Platform 4,086 colectomies 36 ISQIC hospitals January 1 st, 2015 through June 30 th, % capture for colectomies
8 Failure Rate Significant Variation in Best-Practice Chemoprophylaxis Adherence 60% 50% 40% 30% 20% 10% 0% Hospital Median (IQR): 95 cases (64-141) Range cases
9 Failure Rate ISQIC Measure is More Informative than SCIP-VTE-2 20% 18% Patient Off Unit Patient Off Unit 16% Incorrect Order Incorrect Dose 14% Patient Refusal Not Ordered 12% 10% 8% Not Ordered Patient Refusal 6% 4% 2% Missed Other Missed Other 0% Unknown Unknown SCIP-VTE-2 Comprehensive VTE Chemoprophylaxis Measure
10 Predictors of Failure to Provide Best-Practice VTE Chemoprophylaxis Factor 1 Any Failure Reason Odds Ratio (95% CI) P-value Age 40 years 1.0 (Referent) years 0.75 ( ) years 0.61 ( ) > 80 years 0.70 ( ) 0.08 Safety Net Hospital No 1.0 (Referent) Yes 1.60 ( ) 0.04 Magnet Hospital No 1.0 (Referent) Yes 0.49 ( ) Insignificant factors: sex, race, number of comorbidities, smoking status, case mix index, resident to bed ratio, elective procedure 1 Multivariable logistic regression model clustered by hospital. Safety Net Hospital defined as those hospitals in the top quartile of CMS disproportionate share payments
11 Conclusion Current quality measures inadequately capture postop VTE chemoprophylaxis adherence 18% failure with ISQIC measure vs. 1% with SCIP-VTE-2 Patient refusals and ordering errors are major reasons why patients do not receive appropriate postop VTE chemoprophylaxis Drivers of adherence failure were younger patients, Safety Net Hospitals, and lack of Magnet Status Patient, nursing, physician, and system-focused interventions are needed to improve adherence to comprehensive postop VTE chemoprophylaxis
12 Acknowledgements We would like to thank ISQIC hospital teams (SCRs, surgeon champions, QI designees) ISQIC SC Mentors and PI Coaches ISQIC Coordinating Center
13 Multi-institutional Evaluation of Adherence to Comprehensive Postoperative Venous Thromboembolism Chemoprophylaxis D. Brock Hewitt MD MPH, Eddie Blay Jr MD, Lindsey J Kreutzer MPH, Thomas E Kmiecik PhD, Karl Y Bilimoria MD MS FACS, Anthony D Yang MD MS FACS Illinois Surgical Quality Improvement Collaborative
14 References 1. Bilimoria KY, Chung J, Ju MH, Haut ER, Bentrem DJ, Ko CY, Baker DW. Evaluation of Surveillance Bias and the Validity of the Venous Thromboembolism Quality Measure. JAMA. 2013;310(14): doi: /jama Yang AD, Bilimoria KY. Accurately Measuring Hospital Venous Thromboembolism Prevention Efforts.JAMA. 2016;315(19): doi: /jama Surgical Care Improvement Project. SCIP-VTE-2. Specifications Manual for National Hospital Quality Measures v 2.1c 4. Kinner CV, Ju MH, Kmiecik T, et al. Development of a Novel Composite Process Measure for Venous Thromboembolism Prophylaxis. Medical Care. 2016; 54:
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