Inpatient Surveillance and Postdischarge VTE Rates

Disclaimer: The opinions expressed are those of the authors and not necessarily those of the Department of Veterans Affairs or the US government. Previous Presentation: This paper was presented at the 10th Annual Academic Surgical Congress; February 5, 2015; Las Vegas, Nevada. REFERENCES 1. Cook DJ, Crowther MA, Meade MO, Douketis J; VTE in the ICU Workshop Participants. Prevalence, incidence, and risk factors for venous thromboembolism in medical-surgical intensive care unit patients. J Crit Care. 2005;20(4):309-313. 2. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet. 2012; 379(9828):1835-1846. 3. Reitsma PH, Versteeg HH, Middeldorp S. Mechanistic view of risk factors for venous thromboembolism. Arterioscler Thromb Vasc Biol. 2012;32(3):563-568. 4. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl): 381S-453S. 5. Agnelli G. Prevention of venous thromboembolism in surgical patients. Circulation. 2004;110(24)(suppl 1):IV4-IV12. 6. Wong P, Baglin T. Epidemiology, risk factors and sequelae of venous thromboembolism. Phlebology. 2012;27(suppl 2):2-11. 7. Ruppert A, Lees M, Steinle T. Clinical burden of venous thromboembolism. Curr Med Res Opin. 2010;26(10):2465-2473.

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8. Ruppert A, Steinle T, Lees M. Economic burden of venous thromboembolism: a systematic review. J Med Econ. 2011;14(1):65-74. 9. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318(18): 1162-1173. 10. Mismetti P, Laporte S, Darmon JY, Buchmüller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88(7):913-930. 11. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43(3): 322-330. 12. Kahn SR, Morrison DR, Cohen JM, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2013;7:CD008201. 13. Altom LK, Deierhoi RJ, Grams J, et al. Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events. Am J Surg. 2012;204(5): 591-597. 14. Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Hospital process compliance and surgical outcomes in Medicare beneficiaries. Arch Surg. 2010;145(10):999-1004.

15. Bilimoria KY, Chung J, Ju MH, et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013; 310(14):1482-1489. 16. Ju MH, Chung JW, Kinnier CV, et al. Association between hospital imaging use and venous thromboembolism events rates based on clinical data. Ann Surg. 2014;260(3):558-564. 17. Lawson EH, Louie R, Zingmond DS, et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg. 2012;256(6): 973-981. 18. Mull HJ, Borzecki AM, Loveland S, et al. Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators. Am J Surg. 2014;207(4):584-595. 19. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352(10): 969-977. 20. Cassidy MR, Rosenkranz P, McAneny D. Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. J Am Coll Surg. 2014;218(6):1095-1104. 21. Byrne GJ, McCarthy MJ, Silverman SH. Improving uptake of prophylaxis for venous thromboembolism in general surgical patients using prospective audit. BMJ. 1996;313(7062):917.

Invited Commentary

The Controversy Surrounding Surgical Care Improvement Project–Venous Thromboembolism Process Measures Gilbert R. Upchurch Jr, MD

Holcomb and coauthors1 have nicely described a large series of noncardiovascular patients undergoing surgery in the Veterans Affairs Surgical Quality Improvement Program database from 2006 to 2009 in which “inpatient” and Related article page 520 “outpatient” deep venous thrombosis rates were determined based on inpatient surveillance. This study1 serves as a follow-up on an earlier study in which Altom et al2 documented several important risk factors for venous thromboembolism (VTE) but no association with adherence to Surgical Care Improvement Project (SCIP)–VTE process measures. Not surprisingly, in the study by Holcomb et al,1 there was a positive correlation between inpatient surveillance and inpatient VTEs (R = 0.33, P = .003). Interestingly and importantly, however, there was no significant correlation between inpatient surveillance and either postdischarge surveillance or postdischarge VTE rates. jamasurgery.com

When the data are further examined in detail, it appears similar to the data from other studies in that only 18.8% of patients underwent deep venous thrombosis surveillance, with an overall VTE rate of 1.6%. The usual risk factors associated with increased deep venous thrombosis rates included being older than 60 years of age, insulindependent diabetes mellitus, peripheral vascular disease, a history of myocardial infarction, acute renal failure, and having a malignant neoplasm. I was surprised that obesity was not a risk factor for VTE in this study.1 When I queried the authors about this, they responded that body mass index (underweight and not overweight) was a risk factor for surveillance but not for VTE. Tell that to surgeons who specialize in morbid obesity! The surgical characteristics associated with increased surveillance, and thus increased VTE rates, were orthopedic and neurosurgical procedures, as well as increased postoperative complications. Surveillance rates varied significantly at the hospital level. Not sur(Reprinted) JAMA Surgery June 2015 Volume 150, Number 6

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Inpatient Surveillance and Postdischarge VTE Rates

prisingly, the take-home point from all of this is that sicker patients have more VTEs. I think the most important observation from this study1 is that the proportion of patients meeting the SCIP-VTE process measures and the surgical volume of the respective hospitals were not significantly associated with surveillance or VTE occurrence. Similar to my earlier observation regarding sicker patients getting more VTEs, Holcomb et al 1 documented that patients with a longer postoperative length of hospital stay were associated with increased surveillance rates and increased index VTE rates. Yet, inpatient surveillance was not associated with either postdischarge surveillance or VTE occurrence. Neither predischarge nor postdischarge surveillance was associated with postdischarge VTE rates. So what does all this mean, and how should it change your practice? First, it suggests that the bar for SCIP VTE-1 and VTE-2 process measures are set too low. Holcomb et al1 are quick to ARTICLE INFORMATION Author Affiliation: Department of Vascular and Endovascular Surgery, University of Virginia Medical Center, Charlottesville. Corresponding Author: Gilbert R. Upchurch Jr, MD, Department of Vascular and Endovascular Surgery, University of Virginia Medical Center, PO Box 800679, Charlottesville, VA 22908-0679 ([email protected]).

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point this out in their Discussion, concluding that “increased SCIP-VTE adherence has not been shown to be associated with decreased VTE rates.” They agree that a “lack of robustness” for the SCIP-VTE measures is likely. Extending the requirement for prophylaxis beyond 24 hours is likely required. Second, I agree that SCIP-VTE adherence in its current definition is likely an inadequate marker of hospital quality. Suggesting that further research is required regarding refined VTE prophylaxis and screening seems more than reasonable, especially given all the increased expense of newer prophylactic anti-VTE medications, and the ever-expanding requirement for additional surveillance of both inpatients and outpatients. One hopes that we can continue to better define patients who are at increased risk for VTE and treat this subset of patients more aggressively than others. As guidelines around VTE surveillance and prophylaxis continue to be written, let us hope that our definitions of quality around this subject matter can keep pace.

Published Online: April 1, 2015. doi:10.1001/jamasurg.2015.51.

discharge [published online April 1, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.35.

Conflict of Interest Disclosures: None reported.

2. Altom LK, Deierhoi RJ, Grams J, et al. Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events. Am J Surg. 2012;204(5): 591-597.

REFERENCES 1. Holcomb CN, DeRussy A, Richman JS, Hawn MT. Association between inpatient surveillance and venous thromboembolism rates after hospital

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