Predictive value of the present-on-admission indicator for hospital-acquired venous thromboembolism.

BACKGROUND: Hospital-acquired venous thromboembolic (HA-VTE) events are an important, preventable cause of morbidity and death, but accurately identifying HA-VTE events requires labor-intensive chart review. Administrative diagnosis codes and their associated "present-on-admission" (POA) indicator might allow automated identification of HA-VTE events, but only if VTE codes are accurately flagged "not present-on-admission" (POA=N). New codes were introduced in 2009 to improve accuracy. METHODS: We identified all medical patients with at least 1 VTE "other" discharge diagnosis code from 5 academic medical centers over a 24-month period. We then sampled, within each center, patients with VTE codes flagged POA=N or POA=U (insufficient documentation) and POA=Y or POA=W (timing clinically uncertain) and abstracted each chart to clarify VTE timing. All events that were not clearly POA were classified as HA-VTE. We then calculated predictive values of the POA=N/U flags for HA-VTE and the POA=Y/W flags for non-HA-VTE. RESULTS: Among 2070 cases with at least 1 "other" VTE code, we found 339 codes flagged POA=N/U and 1941 flagged POA=Y/W. Among 275 POA=N/U abstracted codes, 75.6% (95% CI, 70.1%-80.6%) were HA-VTE; among 291 POA=Y/W abstracted events, 73.5% (95% CI, 68.0%-78.5%) were non-HA-VTE. Extrapolating from this sample, we estimated that 59% of actual HA-VTE codes were incorrectly flagged POA=Y/W. POA indicator predictive values did not improve after new codes were introduced in 2009. CONCLUSIONS: The predictive value of VTE events flagged POA=N/U for HA-VTE was 75%. However, sole reliance on this flag may substantially underestimate the incidence of HA-VTE.

CMS' Hospital-Acquired Conditions for the Neurohospitalist.

In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a provision that denies Medicare payment for hospital-acquired conditions (HACs). This provision brings attention to the quality of patient care and the financial impact associated with "never-events" occurring during a patient's hospitalization. Our review of HACs focuses on the 5 which are most pertinent to the neurohospitalist: stages III and IV pressure ulcers, catheter-associated urinary tract infection, vascular catheter-associated infection, manifestations of poor glycemic control, and falls resulting in fractures, dislocations, and/or intracranial injuries. We address why CMS came up with them, their impact on quality patient care and hospital finances, and how the neurohospitalist can continue to participate in the future of HAC prevention and management as they relate to one's patients, hospital, and community.