Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis.

BACKGROUND: Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement. METHOD: In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE. RESULTS: We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance. CONCLUSIONS: Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Improving Care for Critical Care Patients by Strategic Alignment of Quality Goals With a Physician Financial Incentive Model.

BACKGROUND AND OBJECTIVES: The passage of the Affordable Care Act has ignited a shift from the pay-for-performance model to value-based care with a particular relevance in critical care settings. Provider incentive programs are widely considered as a means to reward providers based on the achievement of preset quality metrics. This article aims to demonstrate the effects of a provider incentive program in the critical care delivery system in a large academic center in the Northeastern United States. METHODS: This article describes the results of a retrospective analysis of a performance-driven quality improvement initiative at a critical care facility of an academic medical center using a quasi-experimental pre-/posttest design. A set of quality measures was selected as outcome metrics. Selection criteria for the process measures are as follows: (i) the metric goals should be influenced by the physician's input to a large degree; (ii) the measure must be transparent and accessible within the hospital-wide data reporting system; (iii) the metric that required group effort and interdisciplinary collaboration to achieve; and (iv) the measure must directly affect patient outcome. The outcome metrics are central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), standardized infection ratio (SIR), Foley catheter and central line utilization standardized utilization ratio (SUR), hand hygiene compliance, and adherence to respiratory recovery pathway goals. These metrics were tracked from for 3 years with success defined as achieving set benchmarks for each metric. RESULTS: The average CLABSI SIR and CAUTI SIR across all intensive care units (ICUs) decreased by 44% (P = .05) and 87% (P = .02) over 3 years as well as the central line and Foley catheter utilization falling by 41% and 30%, respectively. Hand hygiene compliance in the ICUs improved for the same period by 27 percentage points, as did compliance with the respiratory recovery pathway program by 4 percentage points. CONCLUSION: The use of a physician-driven financial incentive model in a critical care setting measured by outcome metrics dependent on physician input is successful with rigorous implementation and careful evaluation.