The John Charnley Award. Natural history of thromboembolic disease after total hip arthroplasty.

In 1079 consecutive patients undergoing total hip arthroplasty between 1984 and 1992, complications of thromboembolic disease and related anticoagulation were reviewed for 6 months after hospital discharge, including cost data. Of 347 patients having venograms, 78 (22.5%) had positive results and 269 (77.5%) had negative results for deep venous thrombosis. In patients with negative venograms, 3 (1.1%) were readmitted with 2 symptomatic deep venous thromboses and nonfatal pulmonary embolism. There were no readmissions among the 55 patients who had venographically evident deep venous thrombosis diagnosed and treated with outpatient warfarin. Overall, 3 of 324 (0.9%) patients with true positive or negative venograms were readmitted for complications of thromboembolic disease. In contrast, 12 of 732 (1.6%) patients not receiving contrast venography were readmitted, including 9 (1.2%) deep venous thromboses and 3 (0.4%) nonfatal pulmonary embolisms. Four of 23 patients (17.4%) with untreated calf deep venous thrombosis suffered 2 nonfatal pulmonary embolisms resulting in readmission and 2 fatal pulmonary embolisms outside the hospital. Untreated calf deep venous thrombosis after total hip arthroplasty represents a significant threat of extension to more proximal veins and distant embolization. Routine thromboembolic disease prophylaxis combined with screening contrast venography and selective therapeutic anticoagulation is effective in preventing late thromboembolic disease complications and, compared with a strategy of extended prophylaxis for all, is cost effective management by reducing exposure of the elderly population to outpatient anticoagulant therapy.

Reporting tools for clinical quality improvement.

To support clinical quality improvement (QI), effective quality analysis tools are essential. New strategies that we have incorporated into our routine assessment activities include comparative screening, clinical process benchmarking tables, and run charts for key quality indicators. To target areas for improvement, we use comparative screening. We have access to clinical data for 11 comparable medical centers. Currently, these data are used to identify our ranking relative to the others for mortality, readmission, and length of stay. Diagnosis-related groups and ICD-9-CM clusters serve as clinical groupings with defined minimal case volume requirements to ensure meaningful comparisons. These comparative reports permit our clinical leaders and hospital administrators to focus QI activities. Clinical process benchmarking involves peer-to-peer interfacility communication to identify those factors that create outstanding clinical performance. We successfully have used this tool to support process improvement in cardiac-surgery, administration of patient controlled analgesia, and respiratory therapy. Interdisciplinary QI teams identify the key investigative questions. Team members then contact their counterparts at similar facilities, which differ from our hospital in quality, based on empirical evidence or through comparative screening. The information that is obtained is collated in a tabular format, along with our own information, to permit easy identification of key clinical processes associated with better outcomes. Key quality and utilization goals at our hospital include reducing unplanned readmissions by 10%, achieving a 5% lower average length of stay, and not exceeding Health Care Financing Administration expected mortality rates in any clinical area.(ABSTRACT TRUNCATED AT 250 WORDS)