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Hospital-Acquired VTE Still a Leading Cause of Death

 |  By cclark@healthleadersmedia.com  
   June 21, 2012

Blood clot case counts astonish, and make other adverse events in hospitals pale by comparison. And although a few hospitals are getting better at recognizing the problem, the numbers aren't going down, as two reports from the Centers for Disease Control and Prevention show.

These official reviews of the issue force me to think of these tragedies in a most personal way, because they remind me of the death of my mother, a victim of a pulmonary embolism one week after her first dose of chemotherapy 11 years ago. As she waited in the hospital infusion center for her second dose of chemo, she suddenly couldn't breathe, and suffered a respiratory arrest.

Here are the grim numbers. According to Morbidity and Mortality Weekly Report, each year between 2007 and 2009 in the U.S

  • 547,596 hospitalized patients developed blood clots, or venous thromboembolism (VTE)
  • 348,558 were deep vein thromboses (DVT)
  • 277,549 were pulmonary emboli (PE)

The incidence may be much higher. One estimate puts the number at 900,000 cases and 300,000 deaths," almost all of which are attributable to PE...either among the top five or top three causes of death in the United States." Those figures come from a University of Oklahoma VTE expert who was quoted in another CDC report last August.

About 1.1% of all patients who undergo surgery develop a VTE, or about 100,000 cases a year, according to the U.S. Department of Health and Human Services.

The CDC can't estimate how many VTE cases are hospital-acquired, usually defined as occurring in the hospital or within 90 days of hospital discharge. But at least one-third of all VTEs that occur in hospitalized patients are preventable, says Scott Grosse, the CDC's Associate Director for Health Services Research and Evaluation in an interview. HHS estimates that at least 40% of those VTEs that hospitals don't already catch could be prevented with more aggressive efforts.

Annual direct medical costs for VTE total between $5 billion and $8 billion, not including care for long-term complications, according to the CDC.

Yet institutional culture blocks solutions.

Professional groups disagree on which patients are more likely to develop a clot, or which patients should be given prophylaxis such as blood thinners or mechanical interventions such as pneumatic compression sleeves or anti-embolic stockings, says Greg Maynard, MD, a VTE expert at the University of California San Diego.

Use of Maynard's "Three-Bucket Tool" has so precisely determined which patients should receive prophylaxis, and what kind, the number of preventable hospital-acquired VTE cases dropped at UCSD from 13 in the first quarter of 2005 to two in the first quarter of 2007, he says. Some hospitals that have adopted the tool, such as Banner Health in Phoenix, replicated those improvements, he says.

Even two leading professional organizations, the American College of Physicians and the American College of Chest Physicians, are in disagreement with others over which patients should be placed in high-risk categories.

Maynard likens trends in thinking to a swinging pendulum. Several years ago, "It probably was too far on the side that if someone's in the hospital, they should be on an anticoagulant. Now with new guidelines issued by professional organizations, the pendulum has gone too far in the opposite direction, especially for the medical inpatient."

What is needed is something in the middle, "to exclude people from getting anticoagulants who obviously don't need them, such as people who are ambulating or leaving the hospital the next day, and don't have a lot of risk factors."

And there's lack of agreement on which blood clots are truly preventable, no matter what intervention is used. Many physicians just don't think their patients are at high risk, even if they meet the profile, while others overestimate the risk of bleeding when blood-thinning medications are used, he says.

There's a lack of uniformity on how long high-risk patients should be tracked and given medication. Should intervention stop at discharge, or should patients be on medication for 30 days, when post-discharge blood clots are most likely to form, or for as long as 90 days?

You'd think this would be a higher priority and that more progress would have been made, especially since Medicare in 2008 stopped reimbursing hospitals for extra care resulting from PEs after hip and knee surgeries, and Medicaid has recently followed suit.

You'd think there'd be greater incentives to weigh cost issues more seriously, as hospitals look at bundled or accountable care payment models. But hospital and federal health officials urge patience. Improvement is on the way.

Three efforts are underway to better quantify the problem and reduce VTE in healthcare settings.

1. The first is being launched by CDC, which a year ago launched a collaborative project to standardize how hospitals might report VTE cases to the agency's National Healthcare Safety Network. The idea is to create a model much like the CDC's system for tracking central line bloodstream and urinary tract infections, and ventilator-associated pneumonia.

That might reduce the variation in reporting, as seen on Medicare's Hospital Compare. "The way these VTE cases are diagnosed is through imaging tests, and hospitals differ in the frequency with which these imaging tests are used," Grosse says.

For example, "there's one study that showed that among trauma patients, the rate of DVT varies seven fold between the hospitals that used imaging tests the most and those that used them the least." In other words, he says, the more hospitals looked, the more they found.

Another problem with Hospital Compare's data is that hospitals only report serious blood clots that occur after surgery but not after non-surgical hospitalizations. And only those that occur before the patient is discharged, as opposed to those that happen within 30 or 60 days post discharge are reported.

2.The second effort has to do with Partnership for Patients, the Center for Medicare & Medicaid Innovation's effort to reduce 10 hospital adverse events, including the incidence of VTE, by 50% by 2013. Efforts are in the very early stages.

3.The third effort involves two federally funded surveillance projects, one at the University of Oklahoma and the other at Duke University in Chapel Hill. The projects are trying to capture numbers of cases both that occur in the community and after hospital care.

To those doctors and hospital administrators who say that they're doing all they can now to prevent VTE, Gross replies, "They used to say the same thing about central line-associated bloodstream infections, that they weren't preventable. And now we've shown that most CLABSI are preventable."

The bottom line, Maynard and Gross say, is that there has to be an institutional will to attack VTE. "It has to be on everyone's radar, to have the institutional will to standardize VTE prophylaxis," Maynard says. "Even if they don't agree with the way I do it, (the Three-Bucket Tool) they need to standardize it and then measure it with whatever standard they put in place."

Of course, I'll never know if doctors had tried harder, my mother's PE wouldn't have occurred. At age 75 with cancer and chemotherapy, she was certainly high risk, perhaps 12 on a scale of 20. But I would sure feel better knowing that for those like her today, the odds have greatly improved. She was not at all ready to die.

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