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Postoperative Venous Thromboembolism: The More You Look, the More You Find

Summary and Comment |
October 31, 2013

Postoperative Venous Thromboembolism: The More You Look, the More You Find

  1. Neil H. Winawer, MD, SFHM

Postoperative VTE rates are less a reflection of quality and more a function of variation in diagnostic testing practices.

  1. Neil H. Winawer, MD, SFHM

Postoperative venous thromboembolism (VTE) rates are widely reported metrics that have been incorporated into many quality improvement programs and public reporting initiatives. However, is VTE incidence an accurate measure of quality, reflecting adherence to VTE prophylaxis guidelines?

Researchers examined VTE imaging and event rates from 2009 and 2010 Medicare claims data for almost 1,000,000 surgical discharges (>2700 hospitals) following 11 types of major surgeries. Hospital quality was assessed using VTE prophylaxis and event rates from the Medicare Hospital Compare website. Paradoxically, hospitals with higher rates of VTE prophylaxis adherence were associated with higher rates of VTE events. Hospitals deemed to be of higher quality (e.g., accredited teaching programs, greater surgical volumes) had higher VTE prophylaxis rates but worse risk-adjusted VTE rates. The likely explanation for this paradox was that higher risk-adjusted VTE rates correlated with higher rates of VTE imaging; in other words, performing leg ultrasounds and computed tomography or nuclear lung scans more frequently led to identification of more VTE cases. Mean VTE diagnostic imaging rates ranged from 32 to 167 studies per 1000 discharges.

Comment

This study raises serious concerns about use of venous thromboembolism rates as a quality indicator, because surveillance bias appears to be a confounder. Physicians vary in their level of aggressiveness in looking for postoperative complications and, thus, have different thresholds for diagnostic testing. Given that these current estimates of VTE rates almost certainly are biased, reporting them to the public is inappropriate.

  • Disclosures for Neil H. Winawer, MD, SFHM at time of publication Editorial boards ACP Hospitalist

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