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VTE prevention: Real-world outcome data
Domenico PaganoConsultant Cardiothoracic Surgeon
Clinical Director Quality & Outcomes Research UnitUniversity Hospital Birmingham, UK
‘VTE PREVENTION NHS SHOWCASE’ 16th September 2013
Quality and Outcomes Research UnitUniversity Hospital Birmingham
Primary Care and Population HealthUniversity College London, UK
Death from PE
80% autopsy rate
9% PE
Clinical diagnosis wrong in 84% of cases
What is the incidence in 2013?
Karwinski & Svendsen J Clin Path 1989
VTE-PE Deaths in Europe
Diagnosed Sudden Undiagnosed0
50000
100000
150000
200000
250000
Number
A T Cohen et al VITAE Study, Thrombosis and Haemostasis 2007; 98:756-764
7%
34%
59%
Prev
entio
n
Awar
enes
s Pr
even
tion
Evidence based medicine1970’s
• Trials post surgical thromboprophylaxis– Heparin, aspirin, dextrans
Power to detect reduction fatal PE 0.8% - 0.4%
20,000
Commissioning for Quality and Innovation (CQUIN) 2010-2011
• AIM: Reduce avoidable death, disability and chronic ill health from venous-thromboembolism (VTE)
• METHOD: >90% of all patients admitted to hospital should have VTE risk assessment
• DRIVER: Up to £ 500,000 withheld from large acute trusts who do not achieve target
CQUIN
VTE risk assessment
Intervention (socks, pharmacological)
Patient pathway: From risk assessment to outcome
Reduced VTE(fatal, non fatal)
Outcome for payment Patient and staff awareness of VTE
Increased non fatal VTE, reduced fatal VTE
Outcome of interest
Aim of our study
• Assess whether achieving the CQUIN target had impact on:– VTE Mortality– VTE non fatal hospital readmissions
Study Population163 hospital trusts; July 2010-March 2012
• Principal analysis:– All hospital admission > 3 days
• Supportive analyses:– Admissions < 4 days– Day cases– Clinical sub-groups
Data source
HES ONS UNIFY2
163 Acute TrustsAdmissions between:July 2010-March 2012
Death certificate data Hospital levelVTE-assessment data
Rate of VTE assessment in England
Monthly assessment rate by trust
Summary DataJuly 2010- March 2012
VTE Risk Assessment 17,528.316 80.60%Admissions > 3 days 4,141,041 23.62%VTE-Related Readmissions 8,578 0.21%VTE In-Hospital deaths 4,334 0.10%VTE In-Hospital deaths ( Primary) 1,318 0.03%VTE deaths within 90 days 1,651 0.04%VTE deaths within 90 days (Primary) 895 0.02%
In-Hospital Deaths
Post-discharge Deaths
Primary VTE deaths over time
Statistical Analyses• Non linear mixed models
– Poisson / Mixed error– Log Link Function– Radial Smoother Spline function for time (random effects)– Random Intercepts (Trusts)– Including count of events of interest by trust / month as
response variable– Offset is loge(n) where n is the number of relevant admissions– Fixed effect time is centred scale for month (across 21 months
included)– Fixed effect is whether the trust has achieved quality standards
in the relevant month (binary)
Enabling estimation of the change in risk associated with achieving screening target
End-point definitions
• Primary VTE Death: VTE in Position 1 death certificate
• VTE Related Death: VTE position 1-3 death certificate
• In-Hospital and 90 days post-discharge• Total: in-hospital + 90 days post-discharge• Non-Fatal Readmissions
* VTE ICD-10 codes from the NHS-Outcome Framework 2013/14
Patients >3 days hospital stay
0.5 1 2
Total Primary VTE related deaths 0.85 (0.75, 0.96; p=0.011: n=2213)
Total VTE related deaths 0.92 (0.85, 0.99; p=0.033: n=5985)
Primary VTE related inhospital deaths 0.86 (0.74, 1.01; p=0.061: n=1318)
VTE related inhospital deaths 0.92 (0.84, 1.00; p=0.057: n=4334)
Primary VTE Deaths at 90 days 0.81 (0.67, 0.97; p=0.026: n=895)
VTE related deaths at 90 days 0.91 (0.79, 1.05; p=0.196: n=1651)
VTE related Readmissions 1.04 (0.97, 1.11; p=0.301: n=8578)
Relative Risk (95% CI; p: n = events)
Reduction with Programme
Increase with Programme
*
**
0.2 0.5 1
Primary VTE Deaths at 90 days 0.61 (0.48, 0.79; p=0.0002: n=512)
VTE related deaths at 90 days 0.74 (0.61, 0.90; p=0.003: n=874)
Reduction with Programme
Patients < 4 days hospital stay(excluding day cases)
Relative Risk (95% CI; p: n = events)
Day cases
0.5 1 2
Primary VTE post-discharge deaths <90 days 1.00 (0.68, 1.46; p=0.99: n=192)
VTE related post-discharge deaths <90 days 0.96 (0.73, 1.25; p=0.74: n=393)
Relative Risk (95% CI; p: n = events)
Reduction with Programme
Increase with Programme
Relative Risk Reduction for DeathNon-surgical admissions
In-Hospital
Post-Discharge
Primary Post-discharge
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
P=0.04
P=0.006
P=0.001
% Risk Reduction
0.2 0.5 1 2 5
Total Primary VTE related deaths 0.71 (0.41, 1.25; p=0.232: n=82)
Total VTE related deaths 0.89 (0.66, 1.20; p=0.429: n=305)
Primary VTE related inhospital deaths 0.86 (0.20, 3.63; p=0.839: n=14)
VTE related inhospital deaths 1.05 (0.68, 1.62; p=0.83: n=141)
Primary VTE Deaths at 90 days 0.69 (0.38, 1.25; p=0.220: n=68)
VTE related deaths at 90 days 0.77 (0.52, 1.14; p=0.191: n=164)
VTE related Readmissions 1.04 (0.82, 1.32; p=0.765: n=494)
Hip Fracture CCS Grouping
Relative Risk (95% CI; p: n = events)
Reduction with Programme
Increase with Programme
0.2 0.5 1 2
Total Primary VTE related deaths 0.61 (0.40, 0.94; p=0.025: n=152)
Total VTE related deaths 0.72 (0.57, 0.91; p=0.0054: n=512)
Primary VTE related inhospital deaths 0.70 (0.40, 1.21; p=0.202: n=92)
VTE related inhospital deaths 0.68 (0.52, 0.88; p=0.004: n=389)
Primary VTE Deaths at 90 days 0.46 (0.24, 0.90; p=0.023: n=60)
VTE related deaths at 90 days 0.73 (0.47, 1.14; p=0.163: n=123)
VTE related Readmissions 1.34 (1.08, 1.67; p=0.009: n=556)
Nervous System CCS Grouping
Relative Risk (95% CI; p: n = events)
Reduction with Programme
Increase with Programme
Estimation lives savedBased on 2011 if all hospitals achieved 90% screening rate
430
Conclusions
• There is evidence to support an impact of the National VTE CQUIN in reducing hospital associated VTE mortality but not VTE readmissions.
• The effect is also seen in patients with duration of admission <4 days.
• Further subgroup analysis is required to refine which patient groups are benefiting and which patient groups should be considered for additional interventions.