Miriam E. Tucker

May 24, 2013

NATIONAL HARBOR, Maryland — Computerized feedback and pay-for-performance incentives significantly improve compliance with risk-appropriate venous thromboembolism (VTE) prophylaxis, a new study shows.

"The key message is that organized feedback can change provider behavior and help achieve performance goals," said Henry Michtalik, MD, from the Johns Hopkins University School of Medicine in Baltimore, Maryland.

"The study is unique because it looked at the use of combined interventions to improve guideline adherence in the hospital setting, with specific individualized performance benchmarks and goals," he told Medscape Medical News.

Dr. Michtalik presented findings from the study, which was 1 of 3 best of oral abstracts, here at Hospital Medicine 2013.

The approaches used in the study — computerized physician order entry with decision support, individualized feedback on a computer dashboard, and pay for performance — have all typically been used to increase compliance and achieve performance benchmarks.

"In this era of computerized order entry, strategies to get doctors to do more of what's recommended are useful," said Scott Flanders, MD, from the University of Michigan at Ann Arbor.

Dr. Flanders presented another of the best of abstracts, which showed that the extent of a hospital's use of VTE prophylaxis has no impact on subsequent rates of VTE, either in-hospital or at 90 days.

He noted that the findings presented by Dr. Michtalik extend beyond VTE itself, and demonstrate the importance of modifiable computerized systems in hospitals to improve adherence to appropriate medical practice.


Dr. Michtalik and his team examined the use of VTE prophylaxis in a 720-bed tertiary care academic medical center using computerized order entry with decision support. At that center, VTE prophylaxis guidelines from the American College of Chest Physicians (ACCP) were incorporated into the admission order sets for all admitted adults. The computerized order entry system functions primarily to streamline and standardize medication orders.

A system of hospitalist-specific and group dashboards was then implemented to provide direct feedback. The dashboards consisted of a series of graphic displays that provide snapshots and historic trends of key performance indicators. "Like the dashboard of a car, it provides important information to the user that he/she can use in planning and decisions," Dr. Michtalik explained.

The pay-for-performance program was implemented about 6 months later. Hospitalists achieving ACCP-compliance VTE prophylaxis rates of 80% to 100% were paid an additional $0.125 to $0.50 per relative value unit of work. No payments were made to individual hospitalists whose ACCP-compliant VTE prophylaxis rate was below 80%.

The total pay-for-performance payments for an entire year were less than the cost of a single VTE event.

The dataset involved 4119 patients admitted by 38 hospitalists. The most frequent diagnoses were heart failure, acute kidney failure, syncope, pneumonia, and chest pain. The median length of stay was 3 days.

Compliance with VTE prophylaxis guidelines was 84% with computerized order entry with decision support, 90% after the dashboard was added, and 94% after the pay-for-performance program was implemented. The impact was significant for the dashboard (P < .001) and for the pay-for-performance program (= .01).

Total payment to the 19 hospitalists who met the 80% compliance threshold was $12,029 (mean, $633 per hospitalist). By comparison, the cost of a single preventable VTE event ranges from $10,000 to $20,000.

"The total pay-for-performance payments for an entire year were less than the cost of a single VTE event," Dr. Michtalik noted.

There were no similar increases in guideline adherence over the same time period for the general medical service, which operated with only the computerized physician order entry with decision support, suggesting that temporal trends did not factor into the improvement.

Analysis of the 17 hospitalists who were present for the entire study period demonstrated similar improvements, so physician turnover was likely not a factor, he said.

Institutions can design these systems to meet their own needs, Dr. Michtalik told Medscape Medical News. They can be tailored to the "priorities and benchmarks of the institution, state, and nation. The key is to select the combination of tools that are appropriate to the specific program and institution involved."

Tailored Benchmarks

If an institution wants to target readmission rates, for example, the feedback system can focus on that. "These are tailorable metrics," he said. At Johns Hopkins, "we used the existing systems to minimize provider reporting burden and implemented benchmarks that were consistent with state and national benchmarks and goals for quality with respect to VTE prophylaxis," he explained.

Such endeavors do "require an infrastructure to be in place and an institutional commitment," he acknowledged.

Dr. Flanders pointed out that the flexibility of such systems should allow for adjustment as new information arises, such as the data indicating that current guidelines for identifying patients who are candidates for VTE prophylaxis might need to be revised.

"For hospitals and groups that are putting processes in place to deliver the right treatment to the right patient at the right time, those lessons are still going to apply if we change that treatment," Dr. Flanders told Medscape Medical News.

Dr. Michtalik and Dr. Flanders have disclosed no relevant financial relationships.

Hospital Medicine 2013: Society of Hospital Medicine (SHM) Annual Meeting. Presented May 18, 2013.


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