AHRQ PSIs: What We Have Learned (Text Version)

On September 19, 2009, Martha J. Radford, MD made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation ( 1.2 MB). Plugin Software Help.731

Slide 1

Hospital-Acquired VTE: What We Have Learned

Martha J. Radford, MD

Chief Quality Officer

NYU Langone Medical Center

September 2009

Slide 2

VTE Prevention in the USA

Slide 3

VTE Prevention in the USA

Slide 4

VTE Prevention at NYULMC

Slide 5

We Learned from AHRQ Validation:
Our Coding Needs Improvement

• Of the 17 2006 VTE PSI cases we reviewed for the AHRQ validation study, our coding was incorrect for 5 (29%).
• This began a focus on VTE coding quality that continues today.
• The appearance of VTE following ortho procedures as a HAC has solidified the need for accurate VTE coding.

Slide 6

NYULMC VTE Coding Accuracy

2006: 71%
2007: 73%
2008: 84%
2009Q1 (HAC): 89%
2009Q2 (HAC): 100%

Slide 7

Coding Errors at NYULMC

• One fourth to one third: no evidence for VTE
• Two thirds to three fourths: VTE was present on admission
  
  • If date of study demonstrating VTE was after the date of admission, VTE not coded as "present on admission".
    

Slide 8

Coding Interventions at NYULMC

• Outreach to coders about impact of their coding on quality and safety assessment.
• Ongoing feedback to coders about coding errors
• Organizational focus on clinical documentation, clinical documentation specialists interact frequently with coders.

Slide 9

Actual Hospital-Acquired VTE

Among cohorts we reviewed in detail, we have seen a drop in the proportion that are potentially preventable., from about 60% in 2006 to about 40% in 2008.  Among orthopedic cases, HACs appear to have made a big difference.  The proportion of potentially preventable hospital acquired VTE has dropped from about 75% in 2009 Q1 to less than 20% in 2009 Q2.  This is because HACs have high visibility throughout our organization.  They have captured the attention of senior management.

Slide 10

VTE Prevention at NYULMC

A broad outline of the interventions we at NYULMC have put in place to eliminate preventable hospital-acquired VTE events includes:

• Internal SCIP measurement, prior to the requirement for public reporting, in 2006.
• Development of department standards for VTE prophylaxis in 2007.
• In 2008 we updated our CPOE platform, which had been in place for over 15 years. This allowed us to creatively add decision support for VTE prophylaxis to our order sets.
• We have two managed care contracts that include performance on SCIP measures, including VTE prophylaxis.
• The advent of HACs has required us to develop proactive case review for all HACs, including VTE after orthopedic surgery.
• One of our 2010 quality and safety goals will be to eliminate all potentially preventable hospital-acquired VTE. This means that all patients will receive appropriate VTE prophylaxis, including all patients unfortunate enough to develop hospital-acquired VTE.

Slide 11

Department Standards for VTE Prophylaxis

• 2006: Medicine department
• 2007: Surgery departments (8)
• 2008: Departments' CPOE order sets
• 2009: Required order module (medicine)
• 2010: Organization-wide goal to eliminate preventable VTE: ACCOUNTABILITY

Slide 12

Department Standards

• Risk assessment
• Documentation of contraindications to VTE prophylaxis
• VTE prophylaxis ordering options

Slide 13

Medicine Admission Order Set

Medicine started it all, with a module within their admission order set to prompt for VTE prophylaxis.  On the computerized order entry screen, one of the options has always been that VTE prophylaxis is contraindicated.  In addition, a variety of modalities is available for VTE prophylaxis, including subcutaneous unfractionated heparin, enoxaparin, and warfarin.  At first this order module was purely optional.  Similar optional modules were incorporated into surgery departments' admission and postop order sets.

Slide 14

Medicine Admission Order Set: VTE Compulsory
 

As of this year the VTE prophylaxis module is compulsory, including documentation of the reason, if VTE prophylaxis is contraindicated.

Slide 15

Medicine Admission Order Set: VTE Compulsory

You cannot enter entire order set unless either a VTE order is entered or you have documented why VTE prophylaxis is not indicated

 

Slide 16

Surgical Department Standards and Order Sets

• Challenges include:
• Bleeding risk of great concern
• Start VTE prophylaxis on admission, or postop?
• What happens with epidural anesthesia?
• Conflicting guidelines: orthopedics

ALL surgical services place intermittent compression devices before or in the OR, but this may not be sufficient for some patients at particularly high risk.

Slide 17

Increasing Accountability

• Every quarter we send to all department chairs a "quality safety score card" that displays the department's performance on a variety of quality performance measures:
  
  • Administrative measures: admissions, hospital mortality, length of stay, 30-day readmissions.
    
  • Nationally-reported quality performance measures.
    
  • AHRQ patient safety indicators.
    
  • Internal quality and safety measures.
    

Slide 18

Department Quality-Safety Score Card

Each quality performance measure is listed, followed by the department performance and our organization-wide performance.

We color code each PSI against the University Health System Consortium, about 100 academic medical centers.  We compare each department's rate against that of similar UHC cases.  If the PSI rate for the department is above the mean among UHC patients with similar problems, the cell is red.  If the PSI rate is below the UHC mean for that type of patient, it is green.

Slide 19

Department Score Card: Numerator Cases

We also include a "numerator case list" for all cases identified as a PSI case.  For each numerator case we provide patient identifiers, admission and discharge date, attending physician, which PSI was encountered, the primary procedure, and the principal diagnosis. Departments are invited to use this as an occurrence screen for case review and identification of opportunities to improve their care systems to be sure that each and every case has the best possible chance of avoiding a hospital acquired complication, including VTE. 

This exercise has raised the consciousness of department chairs and faculty about the incidence of VTE complications, and the review has resulted in consideration of changes in practice. General surgery, orthopedic surgery, and cardiovascular surgery are considering starting VTE prophylaxis on admission rather that waiting until postop.

We look forward to being able to supply physician-specific rates for all AHRQ PSIs and other measures. 

• Also included:
  
  • Patient identifiers
    
  • Attending physician

Slide 20

Analytic Report from EMR

Our new EMR platform has allowed us to develop an analytic capability to understand our patterns of care.  This report is accessible to all caregivers.  For each service listed on the left, it provides the rate of administration of pharmacologic VTE prophylaxis within 24 hours of admission for all patients age 50 and older:  number of cases; percent compliant and non-compliant , and how the cases were compliant or non-compliant:   pharmacologic VTE prophylaxis given within 24 hours, cases had a contraindication, prophylaxis given late, or prophylaxis not given at all.  The first two are considered compliant, the last two, non-compliant.  If I click on any service, I will get a complete list of all case attributable to that service, including the attending physician.  Our medicine hospitalists, in particular, are incented to increase VTE prophylaxis on their services.

Slide 21

Internal Quality Report Posted on Intranet

This report describing our rate of hospital-acquired VTE is one of our internal quality reports, and is also displayed on the intranet.  We have been running this report quarterly for several years, and we provide "numerator case lists" upon request.  It is similar to the AHRQ PSI for hospital acquired VTE, but adds the dimension of readmissions within 30 days for VTE, and includes all services, not only surgery services. 

We define hospital-acquired VTE as a discharge diagnosis for pulmonary embolus or deep venous thrombosis that is not present on admission, OR a readmission with VTE diagnosis within 30 days following index discharge.  Prior to the availability of the POA indicator, we used the diagnosis date, that was required in New York State.

For the first time in 2009 Q2 we have seen a drop in our organization-wide hospital-acquired VTE rate, from about 8-9 per 1000 discharges in 2008 to about 6 per 1000 discharges in 2009 Q2.  We believe this is real, and is due to both improved coding and to heightened attention to this important aspect of quality for all hospitalized patients.
 

Slide 22

What Have We Learned?

• Accurate coding needs attention from clinicians.
• Computerized order entry with decision support can be harnessed to improve VTE prophylaxis.
• Decreasing the rate of hospital-acquired VTE—real and apparent—is possible.

Slide 23

What Do Hospitals Need from Measures?

Actionable performance data:

• Timely, reliable measures
• With "drill down" to the "unit of actionability"
  -- For VTE prophylaxis at NYULMC, this is the department

Slide 24

What Has AHRQ Learned?

• What is the variability in hospital coding practice?
• Are the AHRQ PSIs sufficiently reliable as safety measures to permit fair hospital comparison?