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Hospitals Unfairly Penalized for Good Care

A study by Johns Hopkins researchers indicates that hospitals suffer improper financial penalties because of the number of patients who suffer blood clots in the lung or leg. The researchers said the penalties did not take into account clots that occurred despite consistent use of the best preventive therapies.

“We have a big problem with current pay-for-performance systems based on ‘numbers-only’ total counts of clots, because even when hospitals do everything they can to prevent venous thromboembolism events, they are still being dinged for patients who develop these clots,” said Elliott R. Haut, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine.

“Our study of patients just at The Johns Hopkins Hospital identifies a need to dramatically re-evaluate the venous thromboembolism outcome and process measures,” Haut says. “Nearly half of the venous thromboembolism events identified by the state program in the records we reviewed were not truly preventable, because patients received best practice prevention and still developed blood clots.”

Haut, who is also a faculty member at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, adds that if their findings are true across other hospitals in Maryland and the nation for venous thromboembolism (VTE) and similar events, “millions of dollars may be at risk inappropriately for hospitals.”

In a research letter, published in the journal JAMA Surgery, Haut and his colleagues note that state and federal government regulatory agencies, along with health insurers, including Medicare, are increasingly tracking the number of patients who develop blood clots and imposing financial penalties using pay-for-performance policies designed to improve care and patient safety.

But their records review shows that even with the use of blood thinners and other best practices, some patients will still develop clots. Maryland and most other programs look solely at the total number of VTE events without delving further into whether or not patients were given preventive medication appropriately,  said Haut, lead writer of the research study.

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 VTE. Thirty-six patients (28 percent) had nonpreventable, catheter-related upper extremity clots (called deep vein thrombosis), leaving 92 patients (72 percent) with clots that were potentially preventable with medicine, they say. 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 percent) of the 92 patients were prescribed optimal clot-preventing medications, yet only 43 (47 percent) received “defect-free care,” researchers found. Of the 49 patients (53 percent) who received suboptimal care, 13 (27 percent) were not prescribed risk-appropriate clot-preventing drugs, and 36 (73 percent) missed at least one dose of appropriately prescribed medication.

“We know we’re not going to get the VTE rate to zero, but my goal is to have every single one of these events — when they happen — occur when the patient receives best-practice, defect-free care,” Haut says.

The current VTE care goal, set by agencies like the Joint Commission and the Centers for Medicare and Medicaid Services, is that one dose of clot-preventing medication is given to patients within the first day of hospitalization, Haut says, which is not enough: “To reduce preventable harm, policymakers need to re-evaluate how they penalize hospitals and improve the measures they use to assess VTE prevention performance. In addition, clinicians need to ensure that patients receive all prescribed preventive therapies.”