Several organizations have started incorporating Maynard's three-bucket model, including the 650-bed Banner Good Samaritan Hospital in Phoenix.
"We've seen a drop in preventable VTE from 45% in 2009 to 25% in 2011," says Lori Porter, DO, head of Banner's VTE prevention initiative. "We were rather aggressive in saying anyone over 40, acutely ill, or having surgery qualified for pharmacologic therapy and some mechanical compression devices," and without an increased risk of hemorrhage or heparin-induced cytopenia.
Now, she says, "we can say with confidence, the three-bucket model is working."
Costs of caring for VTE events can be huge, and Medicare refuses to pay for extra care when VTE occurs in patients undergoing total hip or knee replacements.
One study of hospitalization costs paid by 30 managed care organizations 10 years ago described costs of $7,594 to $16,444 per patient for added care related to VTE. In another study by UC Irvine researchers in 2010, appropriate VTE prophylaxis resulted in a nearly $2,000 lower cost per discharged patient for 21.7% of patients, compared to the cost for caring for the 78.3% of patients who received partial prophylaxis.
But barriers to VTE prevention are numerous. Many clinicians don't want to administer blood-thinning medications like heparin because they have an exaggerated fear of causing a bleed or a hemorrhage, Maynard and other VTE experts explain. And if patients look healthy, physicians may underestimate the VTE risk, they say. Compounding the problem is the failure to reassess patients' risk routinely during their hospital stay, Maynard says.
"We have failed at providing adequate DVT/PE prophylaxis on a more standardized way across the country," says Geno Merli, MD, chief medical officer and senior vice president of 969-bed Thomas Jefferson Hospital in Philadelphia. "We have a few great places that are champions, but the great majority of hospitals don't do it effectively." He adds that doctors worry about many other issues first, such as infections.
But with more aggressive federal mandates for public reporting of certain blood clot measures expected, followed by pay-for-performance and bundling incentives, the heat is on for hospitals to improve their hospital-associated VTE rates. This is a concern for increased lengths of stay, 30-day mortality, and readmissions penalties, especially since 30 days postdischarge is when many of these events occur.
"Readmission rates for VTE are just about as high as they are for congestive heart failure, in the 20% range," Maynard says.