Venous thromboembolism (VTE) accounts for more than 100,000 deaths per year and costs the health care system about $15,000 per event. Methods to increase appropriate prophylaxis have included computerized physician order entry (CPOE) with decision support, dashboards, and pay‐for‐performance (P4P) programs. In this study, we sequentially examined CPOE‐based decision support alone, group and individualized feedback using a dashboard plus decision support, and a P4P program in conjunction with dashboards and decision support to improve VTE prophylaxis.
CPOE with decision support for appropriate VTE prophylaxis based on American College of Chest Physicians (ACCP) guidelines was incorporated into the admission order sets for all adults admitted to our tertiary‐care academic medical center in 2008. To further improve VTE prophylaxis, a Web‐based dashboard specific to the hospitalist group was launched in January 2011, providing both hospitalist group and individualized hospitalist compliance rates. Benchmarks were determined using this dashboard. After 6 months of feedback only, a P4P program was initiated. No payment was made to individual hospitalists with ACCP‐compliant VTE prophylaxis rates < 80%. Graduated payouts were made for compliance rates of 80%–100% to a maximum of $0.50 per work RVU. Using time series analysis, the percent compliance for the hospitalist group was compared during all 3 periods: CPOE alone, CPOE with dashboard, and CPOE with dashboard tied to P4P. A sensitivity analysis explored the potential impact from physician turnover.
We examined 4119 inpatient admissions by 38 hospitalists from 2008 to 2012. The 5 most frequent primary diagnoses were heart failure, acute kidney failure, syncope, pneumonia, and chest pain. Patients had a median age of 57 years (IQR, 44– 69), APR‐DRG severity of illness score of 2 (2–3), and length of stay of 3 days (2–6). VTE prophylaxis group compliance rates were 84% (95% CI, 83–85), 90% (88–93), and 94% (93–96) for CPOE alone, CPOE with dashboard, and CPOE with dashboard tied to P4P, respectively. Compliance significantly improved with both the use of the dashboard (P < 0.001) and the addition of the P4P program (P = 0.01). Annual individual physician VTE P4P payments ranged from $80 to $1429 (mean, $654; SD ± $364). The total annual cost of the P4P program was $12,422. Sensitivity analysis accounting for physician turnover did not significantly impact the comparisons.
Although CPOE with decision support assists with appropriate VTE prophylaxis, direct feedback using dashboards significantly improved compliance. This effect was further augmented by incorporating an individual physician pay‐for‐performance program. The total P4P payments for an entire year were less than the cost of a single VTE event, suggesting an actual cost savings. Real‐time dashboards and physician‐level incentives may assist hospitals in achieving quality and safety benchmarks and reducing preventable harm.
To cite this abstract:Michtalik H, Carolan H, Streiff M, Haut E, Finkelstein J, Durkin N, Padmanaban M, Lau B, Brotman D. The Use of Individualized Dashboards and Pay‐for‐Performance to Improve Venous Thromboembolism Prophylaxis Compliance by Hospitalists. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 514. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-use-of-individualized-dashboards-and-payforperformance-to-improve-venous-thromboembolism-prophylaxis-compliance-by-hospitalists/. Accessed May 24, 2019.