"Never Events" and VTE

“Never Events” and VTE

If you have not heard of “Never Events”, I encourage all of you to read Rich Fox’s timely commentary in the Healthcare Journal of Northern California on this regulatory phenomenon enacted by CMS (US Centers for Medicare and Medicaid Services) (http://www.hcjnc.com/index.php/editorial-mainmenu-31/45-editorial/219-never-events.html)

Effective October 1, 2008, Medicare stopped reimbursing hospitals for the added costs of treating complications arising during hospitalization that in its view should never happen. As Rich points out, this doesn’t mean that Medicare won’t pay for any of the hospitalization, just the part of the DRG that was added on by the never event.

Venous thromboembolism (deep vein thrombosis and pulmonary embolism) occurring after total knee replacement and hip replacement is one of the ten never events.

A recent commentary in JAMA (JAMA vol. 301, p.1063-1065)explores this item in some detail. The authors point out that currently many hospitalized patients fail to receive adequate VTE prophylaxis. Accordingly, financial incentives should in theory improve clinical outcomes.

However, the assumption seems to be that all venous thromboembolism can be prevented. As the authors state, “VTE prophylaxis is not perfect. The most effective currently available prophylactic regimens do not prevent all thrombotic events following TKA or THA.” Nor is VTE prophylaxis always complication proof. There is a significant risk of bleeding complicating VTE prophylaxis with anticoagulants. The authors point out that this risk is probably underestimated in most clinical trials of anticoagulant prophylaxis because the selection criteria tend to favor younger and healthier individuals.

Hospitals that have a disproportionate population of Medicare patients may suffer because of higher rates of both VTE and bleeding. This may result in disincentives to treat higher risk patients.

The authors also suggest that the rule creates disincentives to perform TKR or THR and orthopedists may shift their practices to other types of procedures, or there may be an outright reduction in the number of medical students choosing orthopedics as their specialty. Somehow the logic of this escapes me, since the financial penalties fall only to the hospitals. But I guess there is always the possibility that eventually doctors themselves may be penalized.

They also suggest that this may actually disincentivize doctors to pursue the diagnosis of VTE, if they fear that this will result in a financial penalty to the hospital. I am not sure I would agree with that either.

Their last point, which is not arguable, is that focusing on TKR and THR actually only accounts for less than 10% of the patients who develop VTE in hospitals. This fails to address all of the other areas where improvements can be made in VTE prophylaxis.

The authors conclude with their strongest point: CMS should link penalties only to cases of post-operative VTE where adequate VTE prophylaxis was not given. The bureaucracy based assumption that all cases of VTE are preventable is simply ridiculous.