Blood Clots Show Limits of Quality Care Penalties

Iflying cadeuciin the world of medicine, blood clots during hospitalization have become synonymous with imperfect care. As many as 600,000 patients per year experience a blood clot, and more than 100,000 die as a result, accounting for between 5 and 10 percent of hospital deaths. Regulatory agencies have taken clots as signals that safety and quality have been compromised, and have instituted significant financial penalties on physicians and hospitals for these “preventable events.”

In reality, clots aren’t always as preventable in real-world practice as they are in theory. Blood clots happen even under conditions of perfect, best-practice patient care, which should be seen as testimony to the limits of penalty schemes aiming to improve the quality of care. These penalties should be re-examined.

In a study recently published in JAMA Surgery of 128 blood clot or venous thromboembolism (VTE) cases, my team found that nearly 50 percent of the cases reviewed at The Johns Hopkins Hospital were not actually preventable. In fact, these patients received perfect care by all objective measures — all appropriate preventive measures were taken, including the prescription of the ideal medication and assuring that every dose of medicine was administered. Yet the blood clots still occurred, and the hospital was still financially penalized.

At the same time, our study exposed instances of inadequate care that would routinely be ignored by most quality measures. The other half of patients reviewed in this study received suboptimal, imperfect care. This means the patient may have been underprescribed blood clot prevention medications, missed a dose or didn’t receive any preventive medication.

Penalties had been applied equally to all VTE outcomes, regardless of whether or not the patients had received optimal care. This suggests a serious disconnect between financial penalties and the practices that would lead to the best patient outcomes because, in our study cohort, penalties for blood clots were applied in cases of perfect and imperfect care alike.

The most commonly used blood clot prevention measurement goal, set by agencies like the Joint Commission and the Centers for Medicare and Medicaid Services, is to administer just one dose of clot-preventing medication within the first day of hospitalization. But a patient may actually require three doses every day for the entire hospital stay to survive. A single dose is clearly an unacceptable standard of care, yet it is nonetheless the basis upon which quality of care penalties are made.

Regulators need to raise the bar and better align penalties with best practices, especially given the stakes: Blood clots kill more people each year than AIDS, breast cancer and car crashes combined. Hospitals and regulators should require that every dose of blood clot-preventing medication is administered at the required intervals instead of relying on a one-dose standard definition.

Rather than using the occurrence of clots alone as a quality measure subject to penalty, a better approach would be to track whether patients at risk for clots are appropriately prescribed and given every dose of clot-preventing medications.

This higher standard of care is feasible. At The Johns Hopkins Hospital, we have implemented programs to monitor patients in need of clot-preventing medicines through the hospital’s electronic medical record system. We have brought the rate of dose ordering, well above the national average, well over 98 percent in some clinical services. Our next step has been to conduct ongoing special training for nurses and patients to ensure that every dose of prescribed medication is offered and accepted. Programs like this should be implemented in all hospitals and considered by regulatory entities’ penalty schemes.

Based on the evidence about penalties assessed for the provision of “by the book” perfect care, it is only reasonable to call on regulators to re-evaluate penalty systems. We know at least in the instance of blood clots that they are penalizing for outcomes that were not truly preventable, lumping together perfect care with care that could have been better.

With patients’ lives and millions of hospital dollars lost to inappropriate penalties, we need policymakers to reevaluate the definition of “preventable events” and change the way hospitals are penalized for them. In doing so, policymakers have an opportunity to align a higher standard of care for patients with a more precise and accurate penalty or reward system.

Elliott R. Haut, M.D., Ph.D. is an associate professor of surgery at the Johns Hopkins University School of Medicine and a faculty member at the Johns Hopkins Armstrong Institute for Patient Safety and Quality.

7 replies »

  1. Good article. I would agree that each case should be looked at individually. If a patient receives optimal care and still acquires a blood clot while hospitalized, why should the hospital be penalized? Medical professionals know that blood clots do not necessarily mean imperfect care and hospitals should not have the pay the price when optimal care was given.

  2. Just measure fibrin degradation products on the next 100 folks with hip fractures as they are discharged. Give rewards to those orthopods and their teams who have the fewest patients showing > FDPs.

  3. Very difficult to improve here. Arterial clots are a different problem from venous. Occult malignancies release thromboplastins. Rheology–physics of fluid flow–very important. Coagulation cascade biochemistry endlessly being improved until there must be several hundred molecules that are involved. No PCP can possibly master this intellectual sector. Health care can reach an OK result here, not superb, but it is going to take medical schools to re-organize their presentations of this knowledge, laboratories to re-organize their testing panels, and more drugs working on more critical hinges in the cascade…. before we can really get to master and control DVTs and arterial thrombi. And the science has to advance a few more decades too.