Going from a KNOWNcomplication…. .... To KNOWN complication. NO VTE Prophylaxis Program2003 - 2010 Copyright SMB and Co.
St. David’s VTE Prophylaxis Program7 Year Follow-up -- since January 2003 Endorsed as significant by our leadership Physician-driven and literature-based Sustained, superior results over a 7-year period: Over two-thirds reduction in hospital-acquired: DVT and Pulmonary Embolus Substantial cost-avoidance savings (more than off-setting Rx costs)
Our Greatest Challenge in Clinical Medicine Eliminate the “DEADLY” Delay !! Copyright SMB and Co.
17 Years !! The Deadly Delay…From Clinical Trials to Clinical Practice…
Good News.. We are Doing BetterScurvy and the British Navy 1601-- Lancaster shows that lemon juice supplement eliminates scurvy among sailors 1747-- Lind shows that citrus juice supplement eliminates scurvy 1795 -- British Navy implements citrus juice supplement 194 Years !!
Standard of Care ? !! Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS
The Happy Medium:Previously “accepted” practices currentlyNot Recommended Aggressive surgery for early breast cancer Hormone replacement for post-menopausal women Vioxx for pain and inflammation Drug eluting stents in off-label indications Not too fast....
Gaining Physician Buy- InChanging the Mind-Set Today you are a medical student. However… ..…You will be a student of medicine the rest of you’re career. Dean of Students I hope there is no physician in this room who is…. ….too old a dog to learn a new trick!
Venous Thrombo-Embolic Disease DVT and Pulmonary Embolism
The Problem of VTE Prophylaxis is Significant “Deep Vein Thrombosis and Pulmonary Embolism represent a major public health problem, exacting a significant toll on the Nation” -- Surgeon General Call to Action, 2008 “[Thromboprophylaxis]…is the number-one strategy to improve patient safety in hospitals” – ACCP Guidelines, 2008 “…a vast number of randomized clinical trials over the past 30 years provide irrefutable evidence that primary thromboprophylaxis reduces DVT and pulmonary embolism” – ACCP Guidelines, 2008 DVT-related PE kills more Americans annually than AIDS and breast cancer combined – Gerotziafas, 2004
Literature ReviewProphylaxis Works !! NewEnglandJournalofMedicine1988: Prophylaxis can reduce: PE’s by one half DVT’s by two thirds Deaths in hospitals NewEnglandJournalofMedicine1999: Prophylaxis in acute medical illness can reduce:
Major Risk Factors--- DVT/ PE Age over 40, especially over 70 Previous DVT Prolonged bed rest/ immobilization Surgery Trauma-especially long bone fractures ICU Ventilator Acute spinal cord injury Smoking Medical Conditions: MI/ Heart failure Stroke Malignancy Hypercoagulable states Chronic lung disease Obesity Pregnancy Estrogen use
VTE DemographicsMedical Opportunity Exceeds Surgical Opportunity Annual number at risk for VTE in US hospitals: 7.7 million medical service inpatients1 4.3 million surgical service inpatients 1 Medical Patients: 50%-70% of symptomatic VTEs 2 70%-80% of fatal PEs4 Anderson, Am J Hematol. 2007 Geerts, Chest. 2008
38.3 x greater DVT/PE Risk 2.8 X greater 1.7 X greater LVEF >45% LVEF 20-44% The Medical Patient and VTE RiskHeart Failure LVEF <20% Howell, J Clin Epidemiol, 2001
The Medical Patient and VTE RiskAcute Respiratory Disease The prevalence of thromboembolic disease in patients hospitalized for respiratory disease is estimated at 8%-25% 1 COPD patients with DVT are older, more likely to be inpatients, more likely to be in the ICU and mechanically ventilated, and more often have concomitant PE 2 Shetty, J Throm Thrombolysis. , 2008 Fraisse, Am J Respir Crit Care Med., 2000
The Medical Patient and VTE RiskCancer Cancer patients are at increased risk for VTE Cancer increases risk 4.1-fold Chemotherapy increases risk 6.5-fold Khorana, J Thromb Haemost. 2007 Heit, Arch Intern Med. 2000
The Medical Patient and VTE RiskCancer Khorana, Journ Thromb Haem, 2007
Long Term Sequella of DVTNot just an isolated incident !! For patients with a single episode of DVT, In an 8 year follow-up: Subsequent DVT: 30% Post-Thrombotic Syndrome: 29% In a 10 year follow up: Subsequent DVT: 40% Prandoni, Ann Int Med, 1996 Prandoni, Hematologica, 2007
The Medical Patient and VTE RiskOther Acute Medical Illnesses Copyright SMB and Co.
Why are Core Measures so Important ? 1. They are evidence-based. Implementing these practices will improveclinicaloutcomes 2. Performance is tracked publicly 3. Hospital (and perhaps physician) reimbursement is based upon performance
DVT and Pulmonary Embolism Surf the Legal Websites
Clinical Safety Regulatory The Right Thing !! Legal DVT Prophylaxis Experience Is the Problem of VTE Prophylaxis Significant ?
VTE Prophylaxis Program Development DVT/ PE Prophylaxis Program A. Increase the awareness of DVT/ PE B. Identify and treat patients at risk
VTE Prophylaxis Program Development A. Increase the awareness of DVT/ PE Get the leadership “On-Board” Communications/ education strategy
8th ACCP Guidelines for DVT Prophylaxis (2008)
Conflicting Guidelines in the Role of Aspirin:8th ACCP Guidelines for DVT Prophylaxis (2008) 2006 AAOS Consensus Guidelines Evidence: Grade I A vs Grade III B
Guidelines for Guidelines There will be MORE guidelines in clinical medicine Guidelines wereNEVERintended to apply to all patients and do NOT take the place of individual physician judgment Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care When so… … DOCUMENTIn the medical recordthat: The patient was seen and evaluated The options were thoughtfully considered The best clinical judgment was used Discussed with the patient
Adverse Outcomes Adverse Outcomes protocols Do Guidelines Help or Hurt? We keep missing the point….. Simply put… Protocols reduce adverse outcomes ! Guidelines improve patient care !
100 98 96 Intervention group Freedom From DVT or PE, % 94 92 Control group 90 0 30 60 90 0 Days Education is Not Enough—The Importance of Hardwiring Kucher , NEJM, 2005
For2010: St. David’s HealthCareExclusion CriteriaSCIP-Compliant Order Sets
Determine what outcomes should be tracked How have we done ?? Measure the Results a. Incidence of Hospital-Acquired: DVT Pulmonary Embolism b. Cost Avoidance
Incidence of Hospital-Acquired DVT and PE Total Cases and Cases Avoided Copyright SMB and Co.
Moment of Truth !! All we really did was reproduce the literature… ….. 20 years later !!
St. David’s HealthCare Cost for VTE Prophylaxis Heparin, LMWH, Fonduparinux for VTE Prophylaxis: Approximately $900,000 per year For seven years: $ 6,300,000
PE $12,595 DVT $9,337 $9,643 MI $6,367 Stroke 12500 0 5000 10000 2500 7500 Average Cost per Admission Cost Avoidance for DVT/ PE1.Average Cost per Admission Bick RL. Clin Appl Thrombosis/ Hemostasis 1999
7 Year Cost Avoidance Savings: $ 2,980,000 PE $12,595 $ 3,651,000 $ 6,631,000 DVT $9,337 $9,643 MI $6,367 Stroke 12000 0 5000 10000 2500 7500 Average Cost per Admission Costs trended at 7% per year Cost Avoidance for DVT/ PE 1.Average Cost per Admission Bick RL. Clin Appl Thrombosis/ Hemostasis 1999
Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year MacDougall, Am J Health-System Pharm, 2006
7 Year Cost Avoidance Savings: $2,903,000 $4,556,000 $7,459,000 Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year Costs trended at 7% per year MacDougall, Am J Health-System Pharm, 2006
St. David’s HealthCare Cost for VTE ProphylaxisBalance Sheet Cost of Rx:$ 6,300,000 Cost-Avoidance: $ 6,631,000 Potential Cases Avoided: 380
More than just the Cost of DrugsDVT Prophylaxis May Reduce the Overall Cost of Care Schumoch, Ann Pharm, 2005
What is the Opportunity for Your Hospital ?A Simple Predictive Model Two things to measure: Annual Med-Surg Admissions Equals Total Admissions minus OB Admissions minus Peds Admissions Baseline % pharmaco-prophylaxis in Med-Surg patients Randomly pull 50 charts and determine the percentage of patients receiving prophylaxis Avoidable DVTs: = (90- Baseline %) X (Med-Surg Admissions) / 80,000 Avoidable PEs: = (90- Baseline %) X (Med-Surg Admissions) / 145,000 Copyright SMB and Co.
Typical Example of a 250 Bed Hospital Copyright SMB and Co.
DVT PE 4. Honor the Data—Take it to the Next Level The Lessons Learned
VaginalDeliveriesandC-Sections VTE is the leading cause of preventable maternal death C-Section Patients: Mechanical compression devices until ambulatory Chemoprophylaxis if other risk factors present New
Full Course of Prophylaxis…Expanding our Horizon New 73% of patients develop DVT in the out-patient setting Of those, 60% were hospitalized in past 3 months Of those, 67% had the event the first month Spencer, Arch Int Med 2007
VTE Incidence After Hip and Knee ReplacementThe Risk Continues Well After the Hospital Discharge Sikorski, J Bone Joint Surg, 1981 White, Arch Int Med, 1998
The Duration of Prophylaxis Exceeds the Typical Length of Stay
From Known Complication…… To Known Complication NO ! Chemoprophylaxis does not prevent VTE; It does eliminate 2/3 of all cases New Almost all VTE’s at St. David’s Healthcare now occur in patients who are alreadyreceiving chemoprophylaxis
Why Wait?VTE Prophylaxis in the Emergency Department
Continuous Improvement CycleNext Steps for 2010 and Beyond Clinical improvement focus areas: AComprehensivePreventionProgram Daily ambulation plan for all patients Prophylaxis initiated in the ED Screening for Exclusion Criteria Prophylaxis throughout the Continuum of Care New
Infection Rates of Zero !Pipe Dream or Reality?National Healthcare Safety Network (NHSN) Report
Change Perfection is unobtainable. But if we chase it, we can catch excellence. Vince Lombardi Change Change
Change Change To the world you may be just one person, But to one person you may just be the world.Unknown Change Change