Screening and Diagnosis of VTE: The More You Look, The More You Find?

There is no current consensus regarding routine screening of high-risk asymptomatic trauma patients for venous thromboembolism (VTE). VTE refers to the presence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Practices among surgeons related to screening for VTE in asymptomatic patients may vary significantly. Supporters of routine screening see benefit in performing a relatively inexpensive and noninvasive test (Duplex ultrasonography), in order to diagnose and treat asymptomatic DVT before it progresses to symptomatic or fatal PE. Others suggest that increased medical testing and treatment of asymptomatic VTE incurs not only the risk associated with anticoagulation treatment, but also unnecessary costs. Surveillance bias (“the more you look, the more you find”) in VTE outcome reporting is perhaps an unintended consequence of varying screening practices. Studies have clearly shown that increasing screening is associated with increasing rates of VTE diagnosis, primarily in trauma patients. This poses significant concern because lower incidence of VTE is considered a marker for higher quality health care. National bodies, including the Centers for Medicare and Medicaid Services, impose financial penalties when some hospitalized patients develop VTE. Furthermore, healthcare consumers may use VTE outcomes data to make decisions about where to seek higher quality care. Since the incidence of VTE is related to screening practices, providers who screen more aggressively by performing more Duplex ultrasounds on asymptomatic patients may identify more cases of VTE and will appear, paradoxically, to provide lower quality care than providers who do not screen or order fewer screening tests. For this reason, some experts argue that the standard of patient safety and quality care should not only focus on the incidence of VTE alone (outcome measure) but should also consider how frequently patients are prescribed and administered VTE prophylaxis according to best-practice guidelines (process measure). A pure process measure approach or combined process and outcome measure may be more effective to identify higher quality care and to ultimately mitigate preventable harm related to VTE.