# Presentation: 683789

## Establishing a Patient-centered National Action Plan for Deep Vein Thrombosis

**Prevention, Treatment, and Research**

**Lisa Hines, MS, BSN**
**Surgeon General’s Workshop on Deep Vein Thrombosis**
**May 8, 2006**

## National Quality Forum

***	******The mission of the NQF is to improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient*****. **

**Notes:**
The National Quality Forum is a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. The mission of the NQF is to improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient.
The specific goals of the NQF are to:1. Promote collaborative efforts to improve the quality of thenation's healthcare through performance measurement and publicreporting;2. Develop a national strategy for measuring and reportinghealthcare quality;3. Standardize healthcare performance measures so that comparabledata is available across the nation (i.e., establish national voluntaryconsensus standards);4. Promote consumer understanding and use of healthcare performance measures and other quality information; and5. Promote and encourage the enhancement of system capacity toevaluate and report on healthcare quality.

## Joint Commission for Accreditation of Healthcare Organizations

**	****JCAHO Mission**
**	****To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.**

**Notes:**
Joint Commission standards address the organization’s level of performance in key functional areas, such as patient rights, patient treatment, and infection control, and the standards focus not simply on an organization’s ability to provide safe, high quality care, but on its actual performance as well. Standards set forth performance expectations for activities that affect the safety and quality of patient care. If an organization does the right things and does them well, there is a strong likelihood that its patients will experience good outcomes. The Joint Commission develops its standards in consultation with health care experts, providers, measurement experts, purchasers and consumers.

## Venous Thromboembolism – Deep Vein Thrombosis/ Pulmonary Embolism  Initiatives

- 2003 – Safe Practices for Better Healthcare
- 2004 – VTE project envisioned
- 2005 – VTE Policy, Practices, Performance
- 						Measures project begun
- 2006 – VTE Draft report with statement of policy,        						17 key characteristics of 	preferred practices and 					2 performance measures issued for 	comment
- 2006 – JCAHO posts 19 measures for comment

**Notes:**
The National Quality Forum has been active with DVT efforts since 2003 and continued to pursue efforts to prevent, identify, and treat DVT and it’s complications.

## Venous Thromboembolism – Deep Vein Thrombosis/ Pulmonary Embolism  Initiatives (cont.)

- 2006 – JCAHO measure development continues;
- 					NQF VTE report with statement of policy, 17 						key characteristics of preferred practices, and    					2 	performance measures issued for NQF 								Member 	vote; and
- 					DVT Summit held
- 2007 – JCAHO measure development complete
- 2008 – NQF endorses additional measures

**Notes:**
Many of the experts in the room are participating in this project, either as a Steering Committee member or as a member of the Technical Advisory Panel. 

## DVT SummitMarch 24, 2006

**Goal: Provide recommendations to create a National Action Plan for a patient-centered approach to DVT prevention, identification, and treatment**
**Attendees:  approximately 100 invited stakeholders representing providers, facilities, consumers, purchasers, and federal policy makers**

**Notes:**
The National Quality Forum hosted a one day workshop Establishing a Patient-Centered National Action Plan for Deep Vein Thrombosis Prevention, Treatment, and Research: A National Summit.  Approximately  100 invited stakeholders representing providers, facilities, consumers, purchasers, and federal policy makers attended.  The day kicked off with an overview of the pathophysiology of DVT followed by personal insights of the devastation of the disease by Melanie Bloom and  Cedric Bills. The rest of the participants’ day was spent in an assigned working breakout session – either consumer, clinical, or research.

## DVT SummitRecommendations

**Research Issues & Recommendations**
- Identified gaps and needs in six areas:  epidemiology, diagnosis, treatment, prevention, public policy, and patient-oriented issues
- Key finding:  Many databases exist that may be amenable to jump-start research

**Notes:**
Epidemiologic research should promote a better understanding of the natural history, risk, and incidence of DVT in various populations.  Additional special populations for which more information is needed were identified as follows: Nursing homes, cancer patients, central venous catheters, pediatric patients, acquired familial thrombophilias, different ethnic ancestries – genetic and nongenetic (behavioral) factors, outpatient surgery,  and  women.
Diagnosis: Physicians’ knowledge of VTE is also a diagnostic issue.  If they aren’t aware of what constitutes signs and symptoms that merit diagnostic tests, patients will not be diagnosed.  Clinical evaluations and clinical prediction rules are needed in order for doctors to know. 
Treatment: New agents should be that they are easier to use and safer, as well as less expensive. Cost effectiveness studies for the various treatment options are needed. Non-pharmaceutical therapy is another area of interest. Safety and effectiveness of patient monitoring as well as self-dosing. Risk stratification and predictors of survival among patients with acute pulmonary embolism. 
Prevention: There are gaps in patient and physician awareness. You have to know signs and symptoms before you can give prophylaxis.
Public Policy: Reimbursement policy, accessibility of care and test results, need for financial and efficiency outcomes needed, mandates or competencies were discussed.

## DVT Summit Recommendations

**Clinical Issues & Recommendations**
- VTE assessment and appropriate prophylaxis is the standard of care for  patients
- Identify gaps and assure education for all healthcare practitioners re same through entry level (basic) and post-graduate (supervised) education
- Promulgate and demonstrate compliance with evidence-based institutional policies for CQI in VTE prevention and care

**Notes:**
         VTE assessment and appropriate prophylaxis is the standard of care for patients.  
o       Note:  The group was not able to come to consensus on whether the scope of this recommendation includes most, all, or setting-specific patients.
         Identify gaps and assure education for all healthcare practitioners regarding the standard of care for VTE through entry level (basic) and post-graduate (supervised) education.
         Promulgate and demonstrate compliance with evidence-based institutional policies for continuous quality improvement (CQI) in VTE prevention and care.
         o       Note: Participants suggested the AHRQ Culture of Patient Safety Survey and the CDC Immunization Practices program as guides for implementation. 

## DVT Summit Clinical recommendations continued

- Continuous life-long self education in content and system processes that are aligned with endorsed, standardized measures (disagreement --- spurred by accreditation, individual licensure/ relicensure, certification, P4P )
- Create and sustain a culture of safety by measuring using tools and implementing performance improvement projects to address  through the healthcare continuum especially at point of transitions
- Cost studies should be conducted of all aspects of patients’ care that highlight cost savings of prevention and appropriate care

**Notes:**
         Continuous life-long self-education of providers in content and system processes that are aligned with endorsed, standardized measures.
 Note:  The group was not able to come to consensus on whether this recommendation should be enforced by accreditation, individual licensure, or relicensure, certification, or pay-for-performance—or whether it should be enforceable at all. 

         Create and sustain a culture of safety by measuring VTE care quality using available tools and by implementing performance improvement projects to address quality through the healthcare continuum, especially at point of transitions. 

Cost  studies that highlight cost savings of prevention and appropriate care should be conducted of all aspects of patient care.
       

## DVT Summit Clinical recommendations continued

- Promulgate coverage of appropriate care by all payers (govt/non-govt)
- All healthcare institutions should provide general VTE education for all patients and specific education to patients at risk of VTE  (disagreement re setting where “all” need education)
- There must be multiple avenues for resource dissemination

**Notes:**
	Promulgate coverage of appropriate care by all payers, both government and non-government.

     All healthcare institutions should provide general VTE education for all patients and specific education to patients at risk of VTE.
o       Note: There was disagreement in the group whether this recommendation is appropriate for all healthcare institutions and/or all patients.

There must be multiple avenues for patient education resource dissemination 

## DVT Summit Recommendations

**Consumer Issues and Recommendations**
- Develop a compelling message
- Ensure the message is consumer friendly
- Deliver the message in multiple ways, in multiple venues, and via a neutral entity

**Notes:**
The groups were also asked to list and provide any areas of conflict and discussion during the respective breakout sessions.  The group did not reach consensus on whether specific prevention strategies should be included in the message.  Not all patients have typical risk factors which contribute to DVT and every case is different, therefore some of the consumer group members felt it unnecessary to include “blanket” statements about prevention strategies.  The group felt that it was imperative to encourage research in the development of guidelines for prevention and treatment of DVT and the cause of effect of prevention strategies.  It was also suggested that public awareness such as breast cancer, heart attack, United Way, etc. were quality platforms on which to build a DVT campaign. 

## DVT SummitNext Steps

- NQF’s work in VTE:
- A patient-centered education and empowerment tool
- Summit proceedings in Summer 2006
- Endorsement of key practices and initial performance measures to improve DVT/VTE care (Spring 2006)
- Endorsement of additional standardized performance measures to monitor whether care is improving (Summer 2007)
- Explore options for continuing the small discussions over the next several months and/or re-convening to assess our progress annually

## For more information

**DVT Summit**
**Lisa K. Hines, MS, BSN**
_**[Lhines@qualityforum.org](mailto:Lhines@qualityforum.org)**_
**NQF/JCAHO Measures**
**Melinda L. Murphy, RN, MS, CNA**
_**[Mmurphy@qualityforum.org](mailto:Mmurphy@qualityforum.org)**_** **