Appendix A: Talking Points to Attract Administration Support for Venous Thromboembolism Prevention Programs

Hospitalized patients are at high risk for venous thromboembolism (VTE).

• More than 2 million Americans suffer from VTE each year, with over half of these individuals developing their VTE in the hospital or in the 30 days post hospitalization. In a large registry trial capturing more than 5,450 patients at 183 sites over a 6-month period, 50 percent (2,726) developed their VTE during hospitalization.
• Most hospitalized patients have at least one risk factor for VTE.
• Every year, 23 million people undergo surgery in the United States. A significant number of these people are considered at high or highest risk for developing VTE.
• Without the benefit of VTE prophylaxis, the incidence of proximal deep vein thrombosis (DVT) and clinical pulmonary embolism (PE) in the majority of surgical patients is unacceptably high. Up to 20 percent of surgical patients in the highest risk category (e.g., those undergoing hip or knee arthroplasty or hip fracture surgery) develop proximal DVT. Proximal DVT is the most dangerous and frequently leads to PE without anticoagulation prophylaxis.
• The medical patient is also at high risk. In a typical hospital, it is estimated that fewer than 5 percent of medical patients could be considered at low risk by most VTE risk stratification methods.
• Medical patients probably account for more than half of all hospital-acquired VTE events. In the DVT FREE Registry study, half the inpatients who suffered from VTE were nonsurgical and had had no surgical procedures in the preceding 3 months.
• Without prophylaxis, the range of DVT risk is from 10 to 26 percent in general medical patients, 17 to 34 percent in patients with myocardial infarction, 20 to 40 percent in patients with congestive heart failure, 11 to 75 percent in patients with stroke, and 25 to 42 percent in general medical intensive care patients.
• A 400-bed hospital with an average prevalence of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year. Around half of these events are potentially preventable (estimates derived from DVT FREE Registry and as yet unpublished University of California, San Diego Medical Center experience)

Venous thromboembolism leads to substantial inpatient costs, morbidity, and mortality.

• One in 10 of the more than 2 million Americans developing DVT goes on to die from PE. These 200,000 patient deaths represent more annual deaths than those from breast cancer, AIDS, and traffic accidents combined.
• Many of these VTE deaths contribute to hospital mortality. PE is the most common preventable cause of death in the hospital. An estimated 10 percent of inpatient deaths are secondary to PE. Patients who survive the initial diagnosis of PE face a mortality rate of 17.5 percent at 90 days.
• Not only do patients with VTE suffer a 30 percent cumulative risk for recurrence, they are also at risk for the potentially disabling post-thrombotic syndrome.
• While many VTEs are clinically silent, symptoms of hospital-acquired VTE often require ongoing therapy and represent a significant morbidity.
• The incremental length of stay and costs of treating a case of a preventable VTE event are substantial. The Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Projects' estimates of incremental inpatient cost are $10,000 per DVT and $20,000 per PE.
• The Centers for Medicare & Medicaid Services is currently considering the inclusion of hospital-acquired DVT and PE in its list of events for which hospitals will no longer be reimbursed.

Effective, safe, and cost-effective measures to prevent hospital-acquired VTE exist.

• Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and PE by 50 to 65 percent.
• Prevention of DVT also prevents PE and fatalities from PE.
• Cost-effectiveness of VTE prophylaxis has been repeatedly demonstrated.
• The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, based on abundant data from meta-analyses and placebo-controlled randomized controlled trials.
• Overwhelming evidence reveals that pharmacologic VTE prophylaxis not only prevents adverse patient outcomes, it is also cost-effective.

The gap between current practice and optimal practice is very large.

• The high prevalence of hospital-acquired VTE is largely due to the underutilization of simple, cost-effective prophylactic measures. Of the 2,726 patients who had their DVT diagnosed while hospitalized in the DVT FREE Registry, only 1,147 (42 percent) received prophylaxis within the 30 days before diagnosis.
• Several prominent organizations acknowledge the magnitude of this implementation gap. The AHRQ report, "Making Healthcare Safer," cited the provision of appropriate VTE prophylaxis as the paramount effective strategy to improve patient safety.
  • "Thromboprophylaxis is the number one patient safety practice to prioritize among the nearly 70 practices reviewed."—AHRQ
  • PE is "the most common preventable cause of hospital death in the United States."—Leapfrog
  • "Physicians and other healthcare providers must be aware of risk factors and risk stratification. Moreover, they must take more aggressive action in screening patients for risk factors and in prescribing preventive interventions."—American Public Health Association
• The current reality in American hospitals is arrestingly substandard, especially considering what could be accomplished with simple, safe, and effective prophylaxis for the at-risk inpatient.

VTE Prevention is increasingly incorporated into public reporting, guidelines, regulatory agency priorities, and national quality initiative priorities.

• Organizations include:
  • The Joint Commission. The Joint Commission is currently piloting measures of VTE prophylaxis, incidence of hospital-acquired VTE, and VTE diagnosis and treatment.
  • Surgical Care Improvement Project, or SCIP
  • Leapfrog
  • AHRQ
  • Centers for Medicare & Medicaid Services.

Reliably preventing VTE in the hospital is inherently complex.

• More education alone won't get the job done.
• VTE risk and bleeding risk vary within patient populations.
• The risk of VTE and the risk of bleeding may change for individual patients several times as they progress through their hospital stay.
• Medication changes, weight, age, renal function, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options.
• Transitions across care providers and locations lead to multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis.
• Thoughtful, evidence-based protocols; multidisciplinary system changes; and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.
• Essential elements are needed for effective and safe prevention of VTE in the hospital.
  • Educational and awareness efforts alone have proven inadequate in increasing appropriate use of VTE prophylaxis. Similarly, order sets and critical pathways not supported by a healthy quality improvement framework are unlikely to succeed.
  • Process redesign and continuous attention must include two essential elements:
    1. Performance of a VTE risk assessment for every patient on admission and regularly throughout hospitalization.
    2. Selection of appropriate prophylaxis by linking the VTE risk to a corresponding menu of proven options.

VTE prevention programs can be cost-effective.

• Achieving optimal prevention of hospital-acquired VTE requires incremental monitoring, educational efforts, system change, and coordination of the services of many hospital divisions, all of which may incur incremental costs.
• This incremental expense can be cost-effective in a variety of settings.
• Costs of VTE prevention initiatives can demonstrate a good return on investment through:
  • Improved length of stay, readmission, morbidity, and mortality rates.
  • Improved documentation of patient acuity and related payment for acuity.
  • Income generated via incremental physician and allied health professional billing.

A roadmap is in place.

• Extensive guidance is available from the literature and consensus conferences.
• The Society of Hospital Medicine has produced a comprehensive guide to effective implementation of VTE prevention programs, using a proven performance improvement framework, firsthand experience, and the collective wisdom of several institutions addressing VTE prevention. The guide includes practical information on:
  • Organizing and managing a multidisciplinary steering committee, reporting into the medical center administration.
  • Practical methods to assess institutional performance in VTE prophylaxis and the identification and tracking of patients with hospital-acquired VTE.
  • Constructing an institutional VTE risk assessment model, and integrating it into workflow and order sets.
  • Methods to bolster chances of success by integration of high-reliability design features and attention to effective implementation techniques.

Summary—Push for Support

• Hospital-acquired VTE is an important issue. Effective, safe, and evidence-based measures to prevent hospital-acquired VTE are currently underutilized at many medical centers, resulting in needless mortality and morbidity.
• Personnel who are ready to address this issue aggressively are needed to reduce the prevalence of hospital-acquired VTE. A number of guides are available to help them achieve their goals.
• Administrative support for an empowered multidisciplinary steering committee is needed.
• Institutional prioritization and the will to standardize and improve systems in the face of substantial cultural and complex barriers is an absolute necessity to achieve breakthrough levels of improvement.
• Improved data collection and reporting, incremental monitoring, creation of metrics, and improved documentation are necessary.
• Depending on how advanced or ambitious the effort, it may be important for the team to lay out a business plan, including specific aim, timeline, personnel, full-time equivalent support, and other required resources.

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