Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism

Abstract

IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown.OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE.DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. MAIN OUTCOMES AND MEASURES Association between hospital performance and time to development of VTE within 90 days of hospital admission.RESULTS A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. CONCLUSIONS AND RELEVANCEThe occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.

Assessing the Caprini Score for Risk Assessment of Venous Thromboembolism in Hospitalized Medical Patients

“…The setting and design of HMS have been previously described. 12,13 Although voluntary, each hospital receives payments from Blue Cross Blue Shield of Michigan and Blue Care Network for participating in the consortium and for data collection.…”

“…12 Using data from this collaborative, we conducted a retrospective study to assess the utility of the Caprini RAM in predicting risk of VTE in hospitalized medical patients.…”

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

“…2–3 Recent evidence suggests that higher rates of VTE prophylaxis in the absence of formal VTE risk stratification may not lead to reduced VTE rates. 4 …”

Hospitalists and Their Impact on Quality, Patient Safety, and Satisfaction

“…13 Research by hospitalists in this area has shown that rates of pharmacologic prophylaxis are low in US hospitals. 14 The Joint Commission and the CMS has a performance measure for VTE prophylaxis aimed at increasing the rate of prophylaxis in hospitalized patients. The Society of Hospital Medicine (SHM) has supported hospitalists in their endeavors toward system-based initiatives to improve quality of care.…”