A Health Care System Approach to IVC Filter Removal
The development and implementation of a performance standard for patients with IVC filters at the OhioHealth Vascular Institute.
Like many health care institutions in the United States, OhioHealth and its health care providers have been challenged in the use and retrieval of inferior vena cava (IVC) filters. The identification of IVC filters for removal has become a quality focus area, which was certainly affected by the national attention from the US Food and Drug Administration (FDA), as well as the highly visible class action litigation that has been advertised nationally. As a health system providing this service, OhioHealth is committed to providing the high-quality care standard outlined by the FDA for implanting IVC filters, with active follow-up by the physician until removal or defined extenuating circumstances at all care sites and a goal of successful outcomes for IVC filter patients throughout the system. To meet this commitment to high quality, the OhioHealth Vascular Institute (OHVI) has utilized its multi-institution, multispecialty members to develop a standard clinical process for patients with IVC filters.
OHIOHEALTH VASCULAR INSTITUTE
Created in 2014, the OHVI attempts to support collaboration among its 11 hospitals, 42 care site locations, and more than 45 clinicians who provide vascular care throughout much of the state. Its mission is to provide the highest-quality vascular care while sharing knowledge and resources and developing “best practice” guidelines for the membership. The OHVI includes hospitals ranging from larger tertiary care facilities to mid-sized and smaller community-based hospitals, which encompass both employed and nonemployed physicians. Like most health care systems, OhioHealth historically had physicians and hospitals independently competing within their own institution, as well as with the larger parent health care system.
To reverse this trend, OhioHealth has developed a national model for cooperative care across a large health care system. The focus is on the patient, with optimized specialty integration and quality outcomes. It has been a challenge to not only develop practice guidelines but also an efficient method for multi-institutional communication. To help meet this challenge in communication, OHVI developed a Health Insurance Portability and Accountability Act (HIPAA)–compliant app that allows all members to view treatment guidelines and also send text messages (including photos and videos) to each other and to referring physicians (Figure 1).
DEVELOPING A PERFORMANCE STANDARD FOR IVC FILTER REMOVAL
The OHVI had already implemented a development and approval process for clinical guidelines, so some groundwork for initiating the process of developing a performance standard for IVC filters had already been completed. The OHVI multispecialty executive team developed clinical guidelines for IVC filter insertion and removal, as well as a position statement (Figure 2). The documents were shared and discussed with the membership at large. The IVC filter insertion and removal clinical guidelines were also posted on the OHVI mobile app. Although the national average for IVC filter removal is 30% to 40%,1 the OHVI adopted a goal of > 70% at 1 year postinsertion.
Next, the OHVI operations committee focused on the current filter removal processes at the various institutions and in the various specialties within OHVI. A questionnaire for baseline assessment was sent to nine groups of physicians (vascular surgery, interventional radiology, and interventional cardiology) and their support staff who were currently placing IVC filters in the OhioHealth system. The OHVI position statement on removal, US Food and Drug Administration reference, and tracking assessment questionnaire were sent in May/June 2016. The results of the questionnaire indicated that only two of the nine groups had a standardized tracking method in place for IVC filter removal, with only one group also tracking outcomes. Two groups responded that they followed patients with IVC filters but did not have a “standard” tracking method or outcome measurement tool. The other five groups did not respond or appear to have any plan in place. One group had a successful process in place, with a > 90% success rate for tracking and removing filters. The components of their process were shared with the other member groups and support staff. Each of the nine groups was then tasked with developing and instituting a formal process for tracking patients and filters. A quarterly outcome data sheet was developed for patient tracking, and all groups agreed to a July 2016 timeline for implementing the tracking system. It was determined that it was too complex to go back to find patients with an existing filter, and instead, the process was developed for future placements.
As of October 2016, all nine groups (100%) had established some type of formal outcome follow-up system and tracking methodology for IVC filter removal. The tracking sheets from the first quarter were evaluated. The results were shared with the OHVI executive team and the membership in open fashion to allow discussion and troubleshooting. The inaugural results for the system are as follows: 79 removable filters were placed for the quarter, with a group high of 36 filter placements and a low of 0. With one-quarter or less of follow-up, three patients (4%) died before filters could be removed. In the remaining 76 patients, 54% (range, 33%–58%) were removed or were scheduled for removal. Twenty-five percent (range, 0%–38%) of patients were in the process of office follow-up to evaluate for removal, whereas the remaining 21% either did not have formal follow-up scheduled (18%; range, 0%–66%) or refused follow-up (3%; range, 0%–6%). When these results are compared to the national average of a 30% to 40% removal rate at 1 year, we believe that our results are very promising.
OhioHealth has experienced improved quality on several fronts after developing a multi-institutional, multispecialty vascular institute in a health care system, which is optimized by an app-based, HIPAA-compliant communications tool. With the help of the OHVI operations committee, areas of quality improvement have been identified and processes have been implemented, resulting in more consistent and improved patient care across the health system.
1. Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011;22:1522-1530.
Gary M. Ansel, MD, FACC
System Medical Chief, Vascular Services OhioHealth
Associate Medical Director
OhioHealth Research Institute
Assistant Clinical Professor of Medicine
Department of Medicine
University of Toledo Medical Center
Disclosures: Consultant to Bard, Cook Medical, and Novate Medical.
Lori Wiseman, BSBA, MSN, RN
System Program Manager, Heart and Vascular Services