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Misclassification of Acceptable Venous Thromboembolism Prophylaxis Leading to Flawed Inferences and Recommendations Regarding Prevention Efforts

Misclassification of Acceptable Venous Thromboembolism Prophylaxis Leading to Flawed Inferences... To the Editor We were interested to read the recent study by the Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative1 published in JAMA Surgery. However, we have concerns that the methodologic flaws in the study may lead to inaccurate inferences. First, the authors report an increased rate of venous thromboembolism (VTE) despite improved prophylaxis, leading to the conclusion that prophylaxis is ineffective. We favor an alternate interpretation; low standards for acceptable VTE prophylaxis lead to a better institutional performance of VTE prophylaxis but not better patient outcomes. The Surgical Care Improvement Project VTE-2 measure defines acceptable perioperative VTE prophylaxis as “appropriate pharmacologic VTE prophylaxis within 24 hours before or after surgery.”1(p713) This unacceptably low standard is likely to misclassify suboptimal care as appropriate. We recently reported this phenomenon as the explanation for the lack of an association between publicly reported VTE prophylaxis rates and outcomes.2 Second, the authors ignore the association of missed doses of pharmacologic VTE prophylaxis with VTE. Louis et al3 reported that deep vein thrombosis was 5-fold more common among surgical patients who missed 2 or more doses of enoxaparin during their hospitalization. We noted that more than 11% of pharmacologic VTE prophylaxis doses are not administered and that 40% of patients miss at least 1 dose of pharmacologic prophylaxis during hospitalization.4 Given the reported mean length of stay (7.9 days), it is likely that many doses of pharmacologic VTE prophylaxis were missed, leading to misclassification of patients as having received appropriate prophylaxis. Finally, the authors fail to specify the types of VTE that were diagnosed, ignoring the fact that deep vein thrombosis and pulmonary embolism have dramatically different incidence rates and clinical implications. Catheter-associated deep vein thrombosis is not preventable with prophylaxis.5 Therefore, inferences about the effectiveness of prophylaxis are inappropriate without exclusion of these events. This study1 addresses an important question, but its methods raise doubts about its conclusions. Unfortunately, the authors’ definition of acceptable care renders unnecessary their following question: “if nonselective perioperative and in-hospital prophylaxis is not successful in reducing rates of in-hospital VTE over time, are we placing patients at undue risk without significant benefit?”1(p716) We should not settle for misclassifying low-quality care as high-quality care. Instead, we must strive to provide defect-free care with the administration of every dose of optimal prophylaxis throughout the hospitalization of a patient. Back to top Article Information Corresponding Author: Elliott R. Haut, MD, PhD, Departments of Anesthesiology and Critical Care Medicine, Emergency Medicine, and Health Policy and Management, and Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed 6107C, Baltimore, MD 21287 (ehaut1@jhmi.edu). Published Online: October 21, 2015. doi:10.1001/jamasurg.2015.3411. Conflict of Interest Disclosures: All authors are supported by a contract (CE-12-11-4489) with the Patient-Centered Outcomes Research Institute entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Dr Haut receives royalties from Lippincott Williams & Wilkins for the book Avoiding Common ICU Errors. He is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism (VTE): Every Patient, Every Time” VHA IMPERATIV Advantage Performance Improvement Collaborative. Additional Contributions: We thank Michael B. Streiff, MD, for his help in revising the manuscript. He did not receive any compensation for his contributions. References 1. Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative; Nelson DW, Simianu VV, Bastawrous AL, et al. Thromboembolic complications and prophylaxis patterns in colorectal surgery. JAMA Surg. 2015;150(8):712-720. PubMedGoogle ScholarCrossref 2. Johnbull EA, Lau BD, Schneider EB, Streiff MB, Haut ER. No association between hospital-reported perioperative venous thromboembolism prophylaxis and outcome rates in publicly reported data. JAMA Surg. 2014;149(4):400-401.PubMedGoogle ScholarCrossref 3. Louis SG, Sato M, Geraci T, et al. Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149(4):365-370.PubMedGoogle ScholarCrossref 4. Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8(6):e66311.PubMedGoogle ScholarCrossref 5. Lau BD, Haut ER, Hobson DB, et al. ICD-9 code–based venous thromboembolism performance targets fail to measure up [published online April 21, 2015]. Am J Med Qual. doi:10.1177/1062860615583547. PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Misclassification of Acceptable Venous Thromboembolism Prophylaxis Leading to Flawed Inferences and Recommendations Regarding Prevention Efforts

Misclassification of Acceptable Venous Thromboembolism Prophylaxis Leading to Flawed Inferences and Recommendations Regarding Prevention Efforts

Abstract

To the Editor We were interested to read the recent study by the Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative1 published in JAMA Surgery. However, we have concerns that the methodologic flaws in the study may lead to inaccurate inferences. First, the authors report an increased rate of venous thromboembolism (VTE) despite improved prophylaxis, leading to the conclusion...
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.3411
Publisher site
See Article on Publisher Site

Abstract

To the Editor We were interested to read the recent study by the Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative1 published in JAMA Surgery. However, we have concerns that the methodologic flaws in the study may lead to inaccurate inferences. First, the authors report an increased rate of venous thromboembolism (VTE) despite improved prophylaxis, leading to the conclusion that prophylaxis is ineffective. We favor an alternate interpretation; low standards for acceptable VTE prophylaxis lead to a better institutional performance of VTE prophylaxis but not better patient outcomes. The Surgical Care Improvement Project VTE-2 measure defines acceptable perioperative VTE prophylaxis as “appropriate pharmacologic VTE prophylaxis within 24 hours before or after surgery.”1(p713) This unacceptably low standard is likely to misclassify suboptimal care as appropriate. We recently reported this phenomenon as the explanation for the lack of an association between publicly reported VTE prophylaxis rates and outcomes.2 Second, the authors ignore the association of missed doses of pharmacologic VTE prophylaxis with VTE. Louis et al3 reported that deep vein thrombosis was 5-fold more common among surgical patients who missed 2 or more doses of enoxaparin during their hospitalization. We noted that more than 11% of pharmacologic VTE prophylaxis doses are not administered and that 40% of patients miss at least 1 dose of pharmacologic prophylaxis during hospitalization.4 Given the reported mean length of stay (7.9 days), it is likely that many doses of pharmacologic VTE prophylaxis were missed, leading to misclassification of patients as having received appropriate prophylaxis. Finally, the authors fail to specify the types of VTE that were diagnosed, ignoring the fact that deep vein thrombosis and pulmonary embolism have dramatically different incidence rates and clinical implications. Catheter-associated deep vein thrombosis is not preventable with prophylaxis.5 Therefore, inferences about the effectiveness of prophylaxis are inappropriate without exclusion of these events. This study1 addresses an important question, but its methods raise doubts about its conclusions. Unfortunately, the authors’ definition of acceptable care renders unnecessary their following question: “if nonselective perioperative and in-hospital prophylaxis is not successful in reducing rates of in-hospital VTE over time, are we placing patients at undue risk without significant benefit?”1(p716) We should not settle for misclassifying low-quality care as high-quality care. Instead, we must strive to provide defect-free care with the administration of every dose of optimal prophylaxis throughout the hospitalization of a patient. Back to top Article Information Corresponding Author: Elliott R. Haut, MD, PhD, Departments of Anesthesiology and Critical Care Medicine, Emergency Medicine, and Health Policy and Management, and Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed 6107C, Baltimore, MD 21287 (ehaut1@jhmi.edu). Published Online: October 21, 2015. doi:10.1001/jamasurg.2015.3411. Conflict of Interest Disclosures: All authors are supported by a contract (CE-12-11-4489) with the Patient-Centered Outcomes Research Institute entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Dr Haut receives royalties from Lippincott Williams & Wilkins for the book Avoiding Common ICU Errors. He is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism (VTE): Every Patient, Every Time” VHA IMPERATIV Advantage Performance Improvement Collaborative. Additional Contributions: We thank Michael B. Streiff, MD, for his help in revising the manuscript. He did not receive any compensation for his contributions. References 1. Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative; Nelson DW, Simianu VV, Bastawrous AL, et al. Thromboembolic complications and prophylaxis patterns in colorectal surgery. JAMA Surg. 2015;150(8):712-720. PubMedGoogle ScholarCrossref 2. Johnbull EA, Lau BD, Schneider EB, Streiff MB, Haut ER. No association between hospital-reported perioperative venous thromboembolism prophylaxis and outcome rates in publicly reported data. JAMA Surg. 2014;149(4):400-401.PubMedGoogle ScholarCrossref 3. Louis SG, Sato M, Geraci T, et al. Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients. JAMA Surg. 2014;149(4):365-370.PubMedGoogle ScholarCrossref 4. Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8(6):e66311.PubMedGoogle ScholarCrossref 5. Lau BD, Haut ER, Hobson DB, et al. ICD-9 code–based venous thromboembolism performance targets fail to measure up [published online April 21, 2015]. Am J Med Qual. doi:10.1177/1062860615583547. PubMedGoogle Scholar

Journal

JAMA SurgeryAmerican Medical Association

Published: Feb 1, 2016

References