Published 9/1/2007
Jill Elaine Hughes

Conflicting measures are creating problems for doctors, hospitals

Orthopaedic surgeons should be aware of discrepancies between quality measures

As orthopaedic surgeons are well aware, the Centers for Medicare and Medicaid Services (CMS) is rapidly moving to the adoption of performance-based measures for determining quality bonuses. Two current programs are the Physician Quality Reporting Initiative (PQRI) and the Surgical Care Improvement Project (SCIP).

Both of these programs are designed to improve clinical quality and patient care by measuring and rewarding the performance of both individual physicians and hospitals. Although AAOS has generally been supportive of these performance-based measurement initiatives at CMS, administrative discrepancies between the two programs are creating problems for both doctors and hospitals.

Different measures for DVT/VTE prophylaxis
Beginning in early August, just a month after voluntary reporting under the PQRI went into effect, the AAOS received several concerned phone calls from both members and hospital administrators. The calls centered on a major discrepancy in how CMS measures performance for hospitals and physicians relative to deep venous thrombosis/venous thromboembolism (DVT/VTE) prophylaxis in common orthopaedic surgery procedures.

After some investigation, AAOS identified a discrepancy between Version 2.3 of the SCIP-VTE-1 (also referred to as “National Quality Forum Consensus Standards for Prevention and Care of Venous Thromboembolism”) performance measure developed by CMS for hospitals and the CMS PQRI Voluntary Reporting Measure #23, “Perioperative Care: Venous Thromboembolism (VTE Prophylaxis),” which is an individual physician measure.

At this time, PQRI Measure #23 allows individual physicians to qualify for the PQRI payment bonus if they use one of the following prophylaxis treatments for DVT/VTE in all common orthopaedic procedures, including joint replacement and hip fracture repair: low molecular weight heparin (LMWH; brand name: Lovenox), low-dose unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux (Arixtra), or mechanical prophylaxis (pressure stockings, massage boots).

The SCIP-VTE-1 measure, however, gives payment bonus credit to participating hospitals only if certain chemoprophylaxis treatments are used for certain procedures. For example, under SCIP-VTE-1, use of LDUH is permitted only for hip fracture surgery—not for hip or knee replacement procedures. In addition, SCIP-VTE-1 does not recognize the use of mechanical prophylaxis for all orthopaedic patients and procedures, which PQRI Measure #23 does.

These discrepancies are understandably creating standard of practice conflicts between orthopaedists and hospital administrators.

What you should do
Until CMS addresses and corrects the problem, AAOS encourages members to inform their hospital administrators of the discrepancy between the two measure sets. Members are also encouraged to refer hospital administrators to the recently released AAOS clinical practice guideline for the prevention of pulmonary embolism in patients undergoing total hip or total knee arthroplasty, which generally corresponds to PQRI Measure #23. A summary of the AAOS clinical practice guideline is available at

In addition, the AAOS has informed CMS of the discrepancies between the two measure sets and is encouraging CMS to correct the discrepancy by 2008.

If you have questions regarding these DVT/VTE measure standards, please contact Jill Elaine Hughes, clinical quality improvement coordinator, at (847) 384-4313 or hughes@aaos.org, or AAOS Medical Director Robert H. Haralson III, MD, MBA, at (847) 384-4040 or haralson@aaos.org.

Jill Elaine Hughes is the AAOS clinical quality improvement coordinator. She can be reached at hughes@aaos.org.