Quality Standards Programme NICE cost impact and commissioning assessment: quality standard for venous thromboembolism (VTE) prevention Introduction

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1 Quality Standards Programme NICE cost impact and commissioning assessment: quality standard for venous thromboembolism (VTE) prevention Introduction NICE quality standards contain a set of quality statements that have been developed by a Topic Expert Group (TEG). Each statement has an accompanying quality measure that can be used to measure compliance with the statements that form part of the standard. As far as possible, quality standards are designed to be resource neutral. This means that the statements they contain have been selected to balance quality with economy. In most cases, where a statement requires additional investment, the NHS will achieve consequential savings that will either match or exceed the initial investment, although this may take some years to happen. In some cases, complying with a quality statement will require a net additional investment. Each quality standard will aim to contain other statements with savings that will compensate. This assessment reviews the potential cost impact and implications for commissioners and service providers of the NICE quality standard for prevention of venous thromboembolism (VTE). It has been developed in conjunction with clinicians and reviewed by the TEG. Because each NHS community will have differing levels of compliance with the standard, the precise cost impact of each standard cannot be estimated at a national level. Cost impact should be assessed locally using the following commentary as a guide to areas that may need to be considered. for VTE prevention 1

2 Background Each year over 25,000 people in England die from VTE contracted in hospital. This is more than the combined annual total deaths from breast cancer, AIDS and road traffic accidents, and more than twenty five times the number of people who die from MRSA per year (House of Commons Health Select Committee, 2005). The main danger is from pulmonary embolism (PE). A thrombus (or blood clot) may form in the lower limb or pelvic veins and then come loose. It can be carried in the blood and lodge in the lungs leading to acute massive PE, which often kills immediately. If the patient survives the immediate haemodynamic consequences, death may still ensue in the days or weeks that follow. Survivors usually require intensive care and may take weeks or months to recover. The initial thrombus is called a deep vein thrombosis (DVT). A DVT is itself a cause of substantial morbidity and may lead to the development of post-thrombotic syndrome (in around 30% of people with DVT), which is associated with chronic swelling and ulceration of the legs. Add this burden of morbidity to the 25,000 deaths and it becomes a massive health problem. The total cost (direct and indirect) to the UK of managing VTE is estimated at 640 million (House of Commons Health Select Committee, 2005). for VTE prevention 2

3 Notes on the cost of the quality standard for VTE prevention Statement 1 Proportion of patients assessed for risk of VTE and bleeding on admission using the clinical risk assessment criteria described in the national tool 1. There will be cost implications for the assessment of patients for risk of VTE and bleeding, collection of data and the production of evidence to demonstrate compliance with this statement. No information for these costs is available; although it is considered that the work may be absorbed as part of routine admission procedures. Any costs are likely to be offset by savings that could be achieved from VTE events or deaths avoided as a result of VTE prophylaxis. Additional savings could also be made as a result of avoiding hospital readmission due to preventive treatment offered. Litigation costs might also be avoided and would be attributable to this statement as a saving. Statement 2 Proportion of patients/carers who are offered verbal and written information on VTE prevention as part of the admission process. There will be costs incurred providing written information to patients. It is likely to have two components initial costs to develop information for patients/carers, and the costs to offer the information. Any costs to be incurred are likely to be small when compared to the potential savings that could be achieved as a result of patients correct use of VTE prophylaxis. Based on the 1 The national tool Risk assessment for venous thromboembolism (VTE) is available from _ for VTE prevention 3

4 national tariff for , an elective spell for treatment of DVT costs commissioners 499 and an emergency spell costs commissioners 1,941. Spells for pulmonary embolism can cost commissioners between 349 and 3,618, depending on whether it is elective or emergency and the level of complications. Statement 3 a) Proportion of patients with anti-embolism stockings fitted and monitored in accordance with NICE clinical guideline 92 Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. b) Proportion of staff responsible for fitting and monitoring anti-embolism stockings who have received training on their use. The costs and savings associated with fitting and monitoring anti-embolism stockings were considered in the costing analysis for NICE Clinical guideline 92. This estimated that providing VTE prophylaxis to hospitalised patients at risk of VTE in England would result in a net saving to the NHS amounting to 0.8 million annually. The cost of the preventive treatments was estimated at 30.1 million nationally with the associated savings amounting to 30.9 million. (Savings per 100,000 population were estimated at 12,000). The training of staff should be incorporated into existing training and continuing professional development programmes. It is not anticipated that this requirement will increase costs further than training already provided. However it will reduce the risk of incorrect use or omitting to use them when required, and the subsequent costs that may be incurred. for VTE prevention 4

5 Statement 4 Proportion of patients with a length of stay in hospital greater than 24 hours who are re-assessed for risk of VTE and bleeding within 24 hours of admission. As with statement 1, there will be cost implications for the assessment of patients for risk of VTE and bleeding, collection of data and the production of evidence to demonstrate compliance with this standard. No information for these costs is available; however costs are likely to be offset by savings that could be achieved from VTE events or deaths avoided as a result of VTE prophylaxis. Additional savings in relation to avoiding hospital readmission following preventive treatments could also be achieved. Litigation costs might also be avoided and would be attributable to this standard as a saving. Statement 5 Proportion of patients assessed to be at increased risk of VTE who are offered appropriate prophylaxis in accordance with NICE clinical guideline 92 Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital Costing analysis for NICE clinical guideline 92 estimated that providing VTE prophylaxis to hospitalised patients at risk of VTE in England would result in a net saving to the NHS amounting to 0.8 million annually. The cost of the preventive treatments was estimated at 30.1 million nationally with the associated savings amounting to 30.9 million. (Savings per 100,000 population were estimated at 12,000). for VTE prevention 5

6 Statement 6 Proportion of patients/carers who receive verbal and written information about VTE prevention as part of the discharge process. As with statement 2 there will be a cost to providing written information, however this will be small when compared to the cost of treatment for patients who do not correctly follow their treatment instructions after discharge or do not seek assistance in a timely manner if problems arise. From the national tariff for , a non-elective spell for treatment of DVT and PE will cost a commissioner between 1,427 and 3,618 depending on the level of complications. Statement 7 Proportion of patients offered extended (post hospital) VTE prophylaxis in accordance with NICE clinical guideline 92 Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. It is important that patients receive extended prophylaxis where appropriate. The costing work for NICE clinical guideline 92 included appropriate prophylaxis on the basis of surgery and risk factors, therefore these costs and savings will have been included in the costs and savings quoted under statement 3. for VTE prevention 6

7 Notes on the commissioning implications of the quality standard for VTE prevention NICE quality standards provide commissioners with definitions of high-quality care across a care pathway. NHS commissioners looking for service improvements can use the quality standards to improve the quality of services commissioned from NHS providers by including quality statements and measures within the service specification element of the standard contract, and by measuring performance against them. In the event of poor performance, commissioners can discuss the level of performance with their providers and address any issues and concerns before introducing more formal contractual remedies. Commissioners working alongside their providers can use the quality standards to negotiate contracts and establish key performance indicators as part of a tendering process and/or part of the commissioning for quality and innovation framework. The NICE quality standards can provide a baseline against which improvements can be measured and rewarded, enabling commissioners to address gaps in service provision, support best practice and encourage evidence-based treatments and care. With respect to VTE prevention, the majority of the care will be commissioned from secondary care providers across the whole range of specialties as it applies to both medical and surgical patients. It is anticipated that the cost of meeting the standard should be contained within the tariff for care provided, and equally the benefit from avoiding VTE events, which can increase the length of hospital stay for patients during their initial admission, will remain with the care provider. In the longer term the cost of meeting the standard, and the resulting benefit will be built into the reference costs on which tariffs for future years will be based. The prevention of VTE events subsequent to discharge that would previously have required readmission will result in the commissioner avoiding paying for the readmission and the provider incurring the costs to treat these patients. for VTE prevention 7

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