Blood Clots Aren't Never Events, Researchers Say

Treating blood clots as a "never event" under pay-for-performance guidelines doesn't reflect reality, says a researcher who is calling for a re-evaluation of venous thromboembolism outcomes and process measures.

Hospitals are incurring unfair financial penalties when their patients suffer from blood clots, even when clinicians can demonstrate they've taken every best-practice preventive measure to reduce complications, according to a study published the July 29 issue of JAMA Surgery.

Elliott R. Haut, MD, lead author of the study, says blood clots are treated as a "never event" under pay-for-performance guidelines and that doesn't reflect reality.

"We all agree that we should eliminate preventable harm. The operative words are is it really preventable," says Haut, who is also an associate professor of surgery at the Johns Hopkins University School of Medicine.

"Some things are truly preventable, these never events such as wrong site surgery or leaving objects in patients by accident after surgery. Those should be never events that happen 0% of the time."

Reducing or eliminating complications such as blood clots are a completely different matter, says Haut, who is also on the faculty at the Johns Hopkins Armstrong Institute for Patient Safety and Quality.

"We are never going to be perfect in medicine. This is not a perfect assembly line where every widget is the same and comes out perfectly each time," he says. "Each patient comes with their comorbidities their sickness, their illnesses and whatever and we know when we do surgery there are risks. Blood clots are another example of this. We can't drive the rate of blood clots down to zero."

For the study, Haut and his team reviewed case records for 128 patients treated between July 2010 and June 2011 at The Johns Hopkins Hospital, and who developed hospital-acquired venous thromboembolism (VTE). All 128 were flagged by the Maryland Hospital Acquired Conditions pay-for-performance program. The researchers looked for evidence that the clots could have been prevented.

Thirty-six patients (28%) had non-preventable, catheter-related upper extremity clots, leaving 92 patients (72%) with clots that were potentially preventable with medicine. Of those, 45 had a clot in the leg, 43 had clot in the lungs and four had both types of clots. Seventy-nine (86%) of the 92 patients were prescribed clot-preventing medications, yet only 43 (47%) received "defect-free care," researchers found.

Of the 49 patients (53%) who received suboptimal care, 13 (27%) were not prescribed risk-appropriate clot-preventing drugs, and 36 (73%) missed at least one dose of appropriately prescribed medication, the researchers said.

The 'Bar is Too Low'
Part of the problem, Haut says, is that the "bar is too low" for quality reporting. The existing VTE care goal, set by the Joint Commission and the Centers for Medicare & Medicaid Services, is that one dose of clot-preventing medication is given to patients within the first day of hospitalization. Haut says that's not enough.

Under current guidelines, he says, "the best 100% perfect hospitals have clinical outcomes for DVT and PE that are exactly the same as the lowest quintile."

"You get credit currently for giving one dose when patients may be in the hospitals for two weeks and they should be getting doses three times a day. They are saying 'we will give you credit because you gave them one dose when they came in' and they don't care about the rest of the hospitalization. That is what we have to fight for."

Haut says the results of his study illustrates the need to re-evaluate venous thromboembolism outcomes and process measures. Nearly half of the VTE events identified in the Maryland study occurred even though patients received best-practice prevention. If hospitals and clinicians can demonstrate that they took every precaution, Haut says they should not be penalized.

'A Very Doable Goal'
"It's two pieces: First pick the right medicine. Second, that patient should receive every single dose while they are in the hospital," he says. "That is a very doable goal. The goal of preventing (deep vein thrombosis) and making that number zero is impossible. But if we can provide defect-free care to patients and they get every single dose of best-practice prophylactics, I'll sleep well at night knowing I did the best thing for the patients, provided the best evidence-based care, and provided every single medication. Some bad events might occur, but then it is not my fault."

"If a patient has a (pulmonary embolism) and dies and we'd missed doses I'd feel horrible. That in my mind is preventable if we had done a better job."