549593 research-article2014

VMJ0010.1177/1358863X14549593Vascular MedicineMcBane

Editorial

Science of health care delivery Re: Venous thromboembolism in hospitalized patients: An updated analysis of missed opportunities for thromboprophylaxis at a university affiliated tertiary care center

Vascular Medicine 2014, Vol. 19(5) 392­–393 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X14549593 vmj.sagepub.com

Robert McBane Venous thromboembolism (VTE) is a common and potentially preventable cause of morbidity and mortality for the hospitalized patient. Hospitalization increases the incidence of VTE more than 100-fold compared with community residents.1 For hospitalized patients, thrombotic events are nearly twice as likely to be pulmonary emboli compared to deep vein thrombosis of the leg.1 Pulmonary embolism (PE) accounts for nearly 10% of all hospital deaths and is one of the most common preventable causes of in-hospital mortality. Often, these pulmonary emboli occur without prior warning and sudden death may be the initial symptom of disease. The risk of VTE continues beyond the hospital stay, with nearly half of all thrombotic events occurring up to 90 days post dismissal.2,3 Underscoring the magnitude of this problem is the fact that there are more than 23 million non-surgical hospital admissions and 50 million inpatient procedures performed each year in the United States.4,5 Although surgery is a well-established risk factor for VTE, the majority of VTE events occur in non-surgical patients.6 With a growing trend toward expanded outpatient delivery of medical and surgical health care, only the very sickest patients are currently hospitalized. VTE prophylaxis is cost effective, safe, affordable and reduces VTE rates by 50–70%, with an acceptably low risk of major bleeding. Without prophylaxis, VTE rates are high for both surgical and non-surgical hospitalized patients. Despite these facts, the utilization rates of guideline-endorsed VTE prophylaxis remain imperfect.7 The science of health care delivery aims to identify and advance variables central to the successful implementation and conveyance of strategies for improving the quality, outcomes and cost of individual and societal health care. Scientific inquiry in this new and growing field combines data analysis, health care delivery research and engineering principles to accomplish these goals. Health care systems research focuses on the design and refinement of care delivery systems and processes to improve efficiencies, diminish errors, and improve the access, quality, and safety of medical care delivery. By incorporating practice stakeholders, scientific information, systems engineering and knowledge dissemination, this new field of medical science strives to transform health care delivery. In the current issue of Vascular Medicine, Ma and colleagues address

the science of health care delivery of appropriate VTE prophylaxis in patients hospitalized at a university-affiliated Montreal hospital.8 After documenting a high rate of preventable venous thrombotic events at their institution, this group implemented an institution-wide policy to improve thromboprophylaxis implementation.9 This policy included education, pocket card distribution to members of the health care team, and preprinted admission order sets for surgical patients to encourage proper VTE prophylaxis use. Compared to the pre-implementation period,9 this group was able to demonstrate a 42% reduction in the potentially preventable VTE rate (39.3% from 67.7%) with their institution-wide VTE prevention effort. Omission of VTE prophylaxis, however, remained the primary reason for inadequacy of VTE prevention in this study. There are a number of reasons for inadequacy of VTE prophylaxis delivery. These include concerns regarding the risk of bleeding, economic burden, and unfamiliarity, or non-endorsement of published guidelines.10 As found by Ma and colleagues,8 one of the primary reasons for low compliance with VTE prophylaxis appears to be omission. With the pressures of a busy practice and the growing trend of hospitalization of only the most complicated and sickest patients, it is easy to understand overlooking VTE prophylaxis. A number of strategies have been developed for improving guideline adherence and adoption of best practices. These include information dissemination through continuing education, real-time systems of audit and feedback, computerized ordering algorithms and reminders, and quality improvement projects with designated implementation and surveillance personnel.10 Passive information dissemination strategies appear to be inferior to active strategies. Computer-based systems with electronic reminders likely Department of Medicine, Mayo Clinic, Rochester, MN, USA Corresponding author: Robert McBane Department of Medicine, Mayo Clinic 200 First Street SW Rochester, MN 55905 USA Email: [email protected]

McBane improve success rates. Multiple active strategies improve outcomes compared to single interventions. Continued refinement of the intervention through serial audits is ideal. An electronic order set employing an ‘opt-out’ strategy with a required explanation for omission has dramatically improved VTE prophylaxis delivery rates at our institution (unpublished data). Another group found that a system employing standardized electronic orders, VTE risk stratification systems such as the Caprini scoring system, electronic reminders, and practice audits reduced VTE rates by an impressive 84%.11,12 In the end, the new science of health care delivery should be called upon to develop tools and systems to assist providers in the implementation of health care known to improve patient outcomes. Executing the delivery of appropriate VTE prophylaxis would seem to be an excellent place to start. Electronic strategies to ‘omit the omissions’ of VTE prophylaxis would be a welcome tool to any medical toolbox. Declaration of conflicting interest The author declares no conflicts of interest.

Funding This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References 1. Heit JA, Melton LJ 3rd, Lohse CM, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clin Proc 2001; 76: 1102–1110. 2. Spyropoulos AC, Anderson FA Jr, Fitzgerald G, et al.; IMPROVE Investigators. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest 2011; 140: 706–714.

393 3. Spyropoulos AC, Hussein M, Lin J, Battleman D. Rates of symptomatic venous thromboembolism in US surgical patients: a retrospective administrative database study. J Thromb Thrombolysis 2009; 28: 458–464. 4. CDC/NCHS National Hospital Discharge Survey, 2010. http:// www.cdc.gov/nchs/fastats/hospital.htm (Accessed August 2014). 5. Adams PF, Kirzinger WK, Martinez ME. Summary health statistics for the U.S. population: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10 2013; (259): 1–95. 6. Cohen AT, Alikhan R, Arcelus JI, et al. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 2005; 94: 750–759. 7. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet 2008; 371: 387–394. 8. Ma KA, Cohen E, Kahn SR. Venous thromboembolism in hospitalized patients: An updated analysis of missed opportunities for thromboprophylaxis at a university affiliated tertiary care center. Vasc Med 2014; 19: 385–391. 9. Arnold DM, Kahn SR, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines. Chest 2001; 120: 1964–1971. 10. Tooher R, Middleton P, Pham C, et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 2005; 241: 397–415. 11. Cassidy MR, Rosenkranz P, McAneny D. Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. J Am Coll Surg 2014; 218: 1095–1104. 12. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg 2010; 251: 344–350.

Science of health care delivery: Re: Venous thromboembolism in hospitalized patients: an updated analysis of missed opportunities for thromboprophylaxis at a university affiliated tertiary care center.

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