Your Medicare QIO Answers Your Questions Physicians

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Your Medicare QIO Answers Your
QuestionsPhysicians the SCIP VTE Measures
Protecting Patients, Perfecting Performance,
Limiting Liability, and Cutting Costs (Whats
Not to Like?)

• Howard Pitluk, MD, MPH, FACS
• VP/CMO, Health Services Advisory Group, Inc.
• Mark Michelman, MD, MBA
• Clinical Director, FMQAI, Inc.
• QIO Quality Improvement Organization. This
  Presentation is brought to you by the QIOs of
  California, Arizona, and Florida

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Todays Panelists
Howard Pitluk, MD, MPH, FACS Vice President and
Chief Medical Officer, Health Services Advisory
Group, Inc. Mark Michelman, MD, MBA Clinical
Director, FMQAI, Inc.
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Sponsoring Organizations

• Health Services Advisory Group, Inc.
• Medicare Quality Improvement Organization for
  Arizona since 1979.
• Health Services Advisory Group of California,
  Inc.
• Medicare Quality Improvement Organization for
  California since 2008
• FMQAI, Inc.
• Medicare Quality Improvement Organization for
  Florida since 1993.

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Q1 What is SCIP?
www.medqic.org/scip
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Surgical Care Improvement ProjectNational Goal

• To reduce preventable surgical morbidity and
  mortality by 25 by 2010.

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SIP/SCIP National Expert Panel/Steering Committee

• American College of Surgeons
• American Hospital Association
• Agency for Healthcare Research and Quality
• American Association of Critical Care Nurses
• American College of Chest Physicians
• American College of Obstetricians Gynecologists
• American Geriatrics Society
• American Academy of Orthopedic Surgeons
• American Society of Anesthesiologists
• American Society of Health System Pharmacists
• Association of Professionals in Infection Control
  and Epidemiology

• Association of PeriOperative Registered Nurses
• Centers for Disease Control and Prevention
• Centers for Medicare Medicaid Services
• Department of Veterans Affairs
• Institute for Healthcare Improvement
• The Joint Commission
• Society for Critical Care Medicine
• Society of Colon and Rectal Surgeons
• Surgical Infection Society
• Society for Healthcare Epidemiology of America
• Society of Thoracic Surgeons
• The Medical Letter
• Sanford Guide

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Surgical Care Improvement Project (SCIP)

• Preventable Complication Measures
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention

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Surgical Care Improvement Project
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NQF endorsed
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Q2 What are the SCIP/VTE Measures?
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The SCIP VTE-1 Measure

• Description Surgery patients with recommended
  venous thromboembolism (VTE) prophylaxis ordered
  anytime from hospital arrival to 24 hours after
  Anesthesia End Time.
• The information on this and the following slides
  is adapted from the Specifications Manual for
  National Hospital Inpatient Quality Measures,
  version 3.0b. You can always find the most
  up-to-date information about quality measures in
  the Specifications Manual, which can be found by
  going to www.qualitynet.org, clicking on the
  Hospitals-Inpatient tab, then clicking on the
  Specifications Manual option.

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The SCIP VTE-1 Measure Rationale

• There are over 30 million surgeries performed in
  the United States each year.
• Despite the evidence that VTE is one of the most
  common postoperative complications and
  prophylaxis is the most effective strategy to
  reduce morbidity and mortality, it is often
  underused.
• The frequency of venous thromboembolism (VTE),
  that includes deep vein thrombosis and pulmonary
  embolism, is related to the type and duration of
  surgery, patient risk factors, duration and
  extent of postoperative immobilization, and use
  or nonuse of prophylaxis.

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The SCIP VTE-1 Measure Rationale

• According to Heit et al, 2000, surgery was
  associated with over a twenty-fold increase in
  the odds of being diagnosed with VTE.
• Studies have shown that appropriately used
  thromboprophylaxis has a positive risk/benefit
  ratio and is cost effective.
• Prophylaxis recommendations for this measure are
  based on selected surgical procedures from the
  2004 American College of Chest Physicians
  guidelines (updated in 2008).

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The SCIP VTE-2 Measure

• Description Surgery patients who received
  appropriate venous thromboembolism (VTE)
  prophylaxis within 24 hours prior to Anesthesia
  Start Time to 24 hours after Anesthesia End Time

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The SCIP VTE-2 Measure Rationale

• Timing of prophylaxis is based on the type of
  procedure, prophylaxis selection, and clinical
  judgment regarding the impact of patient risk
  factors.
• The optimal start of pharmacologic prophylaxis in
  surgical patients varies and must be balanced
  with the efficacy-versus-bleeding potential.
• Due to the inherent variability related to the
  initiation of prophylaxis for surgical
  procedures, 24 hours prior to surgery to 24 hours
  post surgery was recommended by consensus of the
  SCIP Technical Expert Panel in order to establish
  a timeframe that would encompass most procedures.

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Q3 Can you help us understand why VTE is such a
high-priority topic?
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VTE Significant Health Impact

• VTE refers to DVT and its most serious
  complication, PE
• VTE is a significant cause of mortality,
  morbidity, and resource expenditure
• DVT occurs in 2 million Americans annually
• PE occurs in 600,000 Americans annually
• 3-month mortality rate with PE is as high as 17
• Fatal PE may be the very first symptom of VTE
• PE is the third most common cause of
  hospital-related deaths in the United States
• Heit JA, Cohen AT, Anderson FA on behalf of the
  VTE Impact Assessment Group. Abstract American
  Society of Hematology Annual Meeting, 2005.

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Annual Fatality Rates in the U.S.
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Q4 What is driving public reporting of these
quality measures, and who supports them?
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Whos Driving the Quality Reporting Initiative?
Professional forces
Consumer forces
Government (CMS, NCQA)
Public reporting (IOM, media)
National quality organizations (JC, NQF)
Consumer demand
Business (PFP, Leapfrog)
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CMSCenters for Medicare and Medicaid Services
JCJoint Commission NCQANational Committee for
Quality Assurance NQFNational Quality Forum.
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Q5 What are the barriers to following the
recommended VTE prophylaxis? (Why are some
physicians unwilling to follow the recommended
evidence-based VTE prophylaxis guidelines?)
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VTE Prophylaxis Perceived Barriers

• I ambulate my patients quickly.
• My patients dont get DVT/PE.
• No literature to support VTE prophylaxis.
• ASA is just fine for all my patients. It was
  good enough 30 years ago and is still good enough
  now.
• Elastic stockings are all you need.
• My patient had a bleeding ulcer 10 years ago
  its too risky to give anticoagulants.

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Responses to Perceived Barriers

• Having bathroom privileges is inadequate for VTE
  prophylaxis.
• Any surgical patient can get a DVT/PE.
• The literature is extensive and quite clear in
  supporting VTE prophylaxis.
• ASA has no value in VTE prophylaxis.
• Elastic stockings (not to be confused with
  Sequential Compression Devices, or SCDs), by
  themselves, are inadequate VTE prophylaxis.
• Remote GI bleeding is not a contraindication for
  VTE chemoprophylaxis.
• Patients over age 40, having general anesthesia
  for more than 30 minutes, and a LOS greater than
  2 days, need some type of prophylaxis.

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Q6 What Can Hospitals Do to Improve on the VTE
Quality Measures?
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What Can Hospitals Do to Implement VTE Quality
Measures?

• Shift the hospital practice paradigm from
  inconsistent risk assessment and periodic
  prophylaxis to evidence-based standardized
  protocols
• Develop a formal, active strategy that addresses
  the prevention of VTE utilizing
• Written, institution-wide thromboprophylaxis
  policy
• Strategies known to increase thromboprophylaxis
  adherence
• Computer decision support systems
• Preprinted orders
• Periodic audit and feedback

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What Can Hospitals Do to Implement VTE Quality
Measures?

• Provide education on VTE as it pertains to
  morbidity, cost, and care measures
• Create and educate a dedicated in-hospital team,
  and provide them with necessary tools to
  implement VTE quality measures
• Hospitalist/Surgeon as chairperson(s)
• Pharmacists and nurses as key team members
• Foster an integrated patient management approach

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What Can Hospitals Do to Implement VTE Quality
Measures?

• Utilize all available quality improvement
  resources and tools (QIO, MedQIC, TJC, IHI, AHRQ,
  etc.)
• Stay aware of the current measures and updates
• Support activities in raising awareness and
  implementation of pending TJC measures
• Partner with organizations in efforts to improve
  quality
• Implement VTE protocols and standing orders

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VTE Prophylaxis Protocols Exist

• Protocols and guidelines for VTE prophylaxis and
  effective treatment in hospital settings are
  available from a number of organizations
• A good source of Orderset/Protocol examples from
  around the country is the Society of Hospital
  Medicine VTE Resource Room http//www.hospitalmed
  icine.org/ResourceRoomRedesign/RR_VTE/html_VTE/12C
  linicalTools/02_Ordersets.cfm
• Additional resources are listed in the
  supplemental document, which will be provided at
  the end of this Webinar.

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Q7 What are the accepted methods for surgical
VTE prophylaxis?
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VTE Prophylaxis Options for Surgery
General Surgery (Appendix A, Table 5.19) Any of
the following Low-dose unfractionated heparin
(LDUH). Low molecular weight heparin (LMWH).
Factor Xa Inhibitor (fondaparinux) LDUH or LMWH
or Factor Xa Inhibitor (fondaparinux) combined
with IPC or GCS. General Surgery with a reason
for not administering pharmacological prophylaxis
(Appendix A, Table 5.19) Any of the following
Graduated compression stockings (GCS).
Intermittent pneumatic compression devices (IPC)
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VTE Prophylaxis Options for Surgery
Elective Total Hip Replacement Any of the
following started within 24 hours of surgery
Low molecular weight heparin (LMWH). Factor Xa
Inhibitor (fondaparinux) Warfarin. Elective
Total Hip Replacement Surgery with a reason for
not administering Pharmacological prophylaxis Any
of the following Intermittent pneumatic
compression devices (IPC). Venous foot pump
(VFP). Elective Total Knee Replacement Any of the
following Low molecular weight heparin
(LMWH). Factor Xa Inhibitor (fondaparinux).
Warfarin. Intermittent pneumatic compression
devices (IPC). Venous foot pump (VFP)
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Q8 What is the impact on patients, physicians,
and hospitals when the measures are not
met?What liability do physicians and hospitals
expose themselves to in not following the
recommended VTE prophylaxis?
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Impact of Not Providing Recommended VTE
Prophylaxis

• When the patient does not receive the appropriate
  VTE prophylaxis, there is significant impact
• Patient is more likely to get a DVT/PE
• Physician is not providing evidenced-based
  medicine
• Non-compliant physicians can have a major impact
  on a hospitals publicly reported data.
• There are potential legal implications for the
  physician and the hospital when there is non-
  compliance with the VTE measures, especially if
  there is an adverse event.

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Hospital-Acquired Conditions October 2008

• Foreign object retained after surgery
• Air embolism
• Blood incompatibility
• Pressure ulcers, stage III and IV
• Falls and trauma (Fx, dislocations, intracranial
  injuries, crushing injuries, burns, electric
  shock

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Hospital-Acquired Conditions October 2008
(Contd)

• 6. Manifestations of poor glycemic control
  (ketoacidosis, nonketotic hyperosmolar coma,
  hypoglycemic coma, secondary diabetes with
  ketoacidosis, secondary diabetes with
  hyperosmolarity) (Forget to order insulin,
  monitor BS)
• 7. Cather-associated UTI
• 8. Vascular catheter-associated infection

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Hospital-Acquired Conditions October 2008
(Contd)

• 9. Surgical site infection following
• CABG?mediastinitis
• Bariatric surgery
• Laproscopic gastric bypass
• Gastroenterostomy
• Laproscopic gastric restrictive surgery
• Orthopedic procedures (spine, neck, shoulder,
  elbow)
• 10. DVT/PE
• Total knee, hip replacement

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Q9 If a physician determines VTE prophylaxis is
not indicated for a particular patient, what
should the physician do to help the hospital meet
measure guidelines for this case?
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Documentation Is Required

• The physician must clearly and legibly document
  in the medical record specific reasons why the
  patient should not receive the recommended
  prophylaxis. If pharmacoprophylaxis is not given,
  the appropriate mechanical prophylaxis should be
  ordered. 

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VTE Prophylaxis Exclusions

• Patients at risk for bleeding or actively
  bleeding may be excluded from pharmacological
  prophylaxis
• Active bleeding (gastrointestinal, cerebral,
  retroperitoneal)
• Bleeding risk
• Patients on continuous IV heparin therapy with 24
  hours before or after surgery
• Thrombocytopenia
• Patient refusal

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Q10 Should VTE prophylaxis continue after
hospital discharge?
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Hospital Stays Are Often Shorter Than Recommended
Prophylaxis Duration

• Average Hospital LOS vs. Recommended Duration of
  Prophylaxis

For chronic obstructive lung disease or
congestive heart failure, estimated from gt200 New
York State hospitals during 1999-2001 for
colonic resection for major joint procedures,
including hip and knee replacement, estimated
from gt200 New York State hospitals during
1999-2001. 1. LOVENOX (enoxaparin sodium
injection) Prescribing Information.
Sanofi-aventis U.S. LLC. June 2007. 2. de Jong JD
et al. Health Serv Res. 200641374-394. 3. Basse
L et al. Ann Surg. 200023251-57.
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The Take-Home Message

• The effectiveness of VTE prophylaxis is well
  documented.
• Most hospitalized patients have at least one VTE
  risk factor.
• VTE prophylaxis is the right thing to do to
  protect the health of our patients.
• Non-compliance can have serious financial, legal,
  and public reporting implications for physicians
  and hospitals.

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The Take-Home Message (Contd)
VTE risk assessment and prophylaxis should be as
fundamental to hospital practice as are the
measurements of pulse, blood pressure,
temperature, height, and weight. For additional
SCIP resources, including the supporting
documents for this Webinar, go to Arizona
http//www.hsag.com/azhospitals/scip/resources.asp
x California http//www.hsag.com/cahospitals/s
cip/resources.aspx Florida http//www.fmqai.co
m/PatientSafety-SCIP-Tools.aspx

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Over 1 million drug-related injuries occur every
year in health care settings. The Institute of
Medicine estimates that at least a quarter of
these injuries are preventable. To find out how
to prevent medication errors, go to (Florida)
http//www.fmqai.com/PatientSafety-FMSI.aspx,
(Arizona) http//www.hsag.com/azproviders/drugsaf
ety.aspx, or (California) http//www.hsag.com/capr
oviders/drugsafety.aspx.
www.hsag.com www.fmqai.com This material was
prepared by Health Services Advisory Group of
California, Inc., the Medicare Quality
Improvement Organization for California Health
Services Advisory Group, Inc., the Medicare
Quality Improvement Organization for Arizona and
FMQAI, Inc., the Medicare Quality improvement
Organization for Florida, under contract with the
Centers for Medicare Medicaid Services (CMS),
an agency of the U.S. Department of Health and
Human Services. The contents presented do not
necessarily reflect CMS policy. Publication Nos.
CA-9SOW-6.2.3-110409-01, AZ-9SOW-6.2.3-110409-01,
FL2009F62ST1611497
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