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Are Higher Hospital Venous Thromboembolism (VTE) Rates an Indicator of Better Quality? Evaluating the Validity of the Hospital VTE Quality Measure Using Clinical Data
Mila H Ju*1, Jeanette W. Chung*1, Christine V. Kinnier*1, David W. Baker*1, David J Bentrem*1, David M. Mahvi1, Clifford Y. Ko2, Karl Y. Bilimoria*1
1Northwestern University, Chicago, IL;2University of California, Los Angeles (UCLA), Los Angeles, CA
OBJECTIVE(S):
Hospital VTE rates are publicly reported and used in pay-for-performance. Prior work suggested surveillance bias: hospitals that look more for VTE with imaging studies find more VTE, thereby incorrectly appear to have worse performance. However, these results have been questioned as the risk-adjustment and VTE measurement relied on administrative data. Our objective was to assess the presence and extent of VTE surveillance bias when using high-quality clinical data.
METHODS:
For 200 hospitals (2009-2010), risk-adjusted postoperative VTE rates (regression models using ACS-NSQIP), VTE imaging use rates (Medicare claims), and VTE prophylaxis adherence (SCIP-VTE-2) were calculated. Hospitals were divided into quartiles by VTE imaging use rates. VTE event and prophylaxis adherence were compared across imaging use quartiles.
RESULTS:
While VTE prophylaxis adherence increased across VTE imaging use quartiles, risk-adjusted VTE rates paradoxically increased (1.1% in the lowest VTE imaging use rate quartile to 1.9% in highest quartile; P<0.001). Hospital VTE imaging use was the strongest predictor of VTE rates (P<0.001). For hospitals in the highest quartile of VTE event rates, 71% had high VTE imaging use rates (i.e., hospitals found more VTE by imaging frequently), while 29% had low imaging use rates (i.e., hospitals with high VTE rate without imaging more frequently - true poor performers).
CONCLUSIONS:
Even when examined with clinically ascertained outcomes and detailed risk adjustment, VTE rates reflect hospital imaging use and perhaps signify vigilant, high-quality care. The VTE outcome measure is not an accurate quality indicator and should not be used in public reporting or pay-for-performance programs.
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