VTE Prevention:The Case for PA Champions

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Marc Moote, MS, PA-CChief Physician Assistant

University of Michigan Health System

Is the PA profession positioned

to drive forward quality improvement

in

U.S. Hospitals (e.g. VTE Prevention)?

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Objectives

• Context: review U.S. healthcare related to quality

• Champions: Why PAs must be change agents to drive forward quality improvement initiatives such as VTE prevention

• Case Example: PA-led VTE prevention effort

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U.S. Healthcare Costs Unsustainable• $2.7 trillion/yr spent on healthcare

• ~$8,000/citizen = highest in the world• Expected to grow 70% by 2018

• 18% of our gross domestic product (GDP)• Projected to reach 20% GDP by 2020

• More than 35% is for hospital-based care, current cost of $18,000 per discharge

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf , www.commonwealthfund.org/.../1595_Squires_explaining_high_hlt_care_spending_intl_brief.pdf, http://www.census.gov/compendia/statab/cats/health_nutrition/health_expenditures.html

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First the Good News…We’ve come a long way

“…for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.”

- Harvard Professor Lawrence Henderson, 1912

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We’ve accomplished great things in U.S. Healthcare• 7 yr life expectancy gain from 1960-2000

• Since 1950, heart disease mortality has declined 60%, stroke mortality 70%

• 18.4% increase in 5-year survival for all cancer types combined

• Performed 28,535 organ & tissue transplants in 2011

N Engl J Med. 2006 Aug 31;355(9):920-7, JAMA. 1999 Aug 25;282(8):724-6, http://www.organdonor.gov/about/statistics.html, http://seer.cancer.gov/faststats/selections.php?#Output

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Yet, there is a quality chasm in the U.S.*

*Bob Pendleton, MD, presented at NATF 2010 Meeting

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We often fail to do the basic things well…• Controlling hypertension (65% reliable)• Colorectal cancer screening (38%) • Controlling Diabetes (45% reliable)• Treating hyperlipidemia (49%)• β-Blockers for MI patients (45% reliable)• VTE Prophylaxis in at-risk patients (40-50%)• Pneumonia vaccines in elderly (64% reliable)

McGlynn et al. NEJM 2003; 348(36):2635-45

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Consequences of The Quality Chasm in U.S. Healthcare

• Preventable Medical Errors in Hospitals:• Over 44,000 - 98,000 Deaths annually in U.S.• Cost estimated $17 – 29 billion annually• 4% of hospital patients suffer complications from

treatment that either prolong their hospital stay, or result in disability or death

• Two-thirds of complications are due to errors in care• Medical Omissions:

• Inadequate care post MI results in 18,000 unnecessary deaths/yr.

• Up to 100,000 patients die from preventable PESource: Kohn LT, Corrigan JM, Donaldson ML. To Err is Human. Washington, DC: National Academy Press, 2000;Atul Gawande, MD. Complications: A Surgeon's Notes on an Imperfect Science, 2002; http://www.ahrq.gov/qual/iompriorities.htm; http://www.surgeongeneral.gov/library/calls/deepvein/call-to-action-on-dvt-2008.pdf

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Healthcare Value

Healthcare Value

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= QualityCost

Conway PH, J Hosp Med 2009;4(8):507-11

Know the Landscape – Regulatory Drivers of Quality

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• Medicare Initiatives• Pay for reporting • Value Based Purchasing• Hospital Acquired Conditions• Readmission Penalties• Never Events

• Joint Commission (TJC) Core Measures & NPSGs• National Quality Forum (NQF) evidence based safe

practices• Agency for Healthcare Research & Quality (AHRQ)

Patient Safety Indicators (PSIs)

CMS Quality Agenda 2012

Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient healthcare

Value Based Purchasing: Payment based on quality

Readmission Penalties: No payment for readmissions for select conditions

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Physician Assistants – Point of Leverage?

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PA Practice Settings

47%

53%

HospitalSetting

Other Settings

Modified from 2010 AAPA Census

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So what?…Economics & Risk

• Most hospitalist physicians cannot survive on billing alone

• 90% of hospitalists receive financial subsidy

• In 2011, the average subsidy was $132,000 per full time hospitalist

• Likewise, PAs in a hospital setting cannot survive on billing alone

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=642, http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1246

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Combined Revenue/cFTE

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Figure 9: Average Annualized Combined (Billable + Bundled) Revenue per cFTE

$97,269

$77,637

$77,286

$134,038

$136,808

$118,884

$103,519

$113,519

$101,152

$141,060

$169,652General Surgery

Heart Failure Transplant

Infusion

Inpatient Hematology

Oncology Team #1

Oncology Team #2

Oncology Team #3

Oncology Team #4

Oncology Team #5

Oncology Team #6

Oncology Team #7

c

Moote, unpublished data 2009

US Hospital LOS Trends*

*Bob Pendleton MD, presented at NATF 2010 Meeting

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Efficiency

Quality

LOS

Mortality

Etc.

EtcEtc.

Discharge time of day/throughput

New Patient Access

Volume/Census/RVU’s/Gross ChargesCoding

Adverse EventsReadmissions

SatisfactionBlood Utilization

Resource Utilization

SCIP MeasuresCore Measures

VTE Prophylaxis

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Know your hospital’s data

• Hospital Score Card & Performance• HCAHPS• Value Based Purchasing• Hospital Acquired Conditions (HACs)• Never Events• Core Measures

• Hospital’s Patient Safety Plan

• Target areas PAs can make an impact 20

In era of constant change within healthcare and declining

reimbursement, PAs MUST deliver quality

improvement

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VTE Prevention: A Case Example of a PA Champion

VTE: Common, Deadly, Preventable

• 300,000 – 2 million Americans will suffer VTE annually in the U.S.

• 1/3 will die of PE, most within first 30 days

• 25% of PEs will present with sudden death

• 1/3 of patients will have recurrence within 10 yrs

• 50% will have long-term complications

(Beckman et al., 2010, Am J Prev Med); (Centers for Disease Control and Prevention [CDC]); (Heit, 2008, Arterioscler Thromb Vasc Biol); (Mahan et al., 2012, Thromb Haemost); (Mahan et al., 2011, Thromb Haemost)

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VTE in the Community

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20%

20%60%

Percent VTE in the Community

Community Acquired (Unprovoked)

Community Acquired (Ac-tive Cancer)

Recent Hospitalization (e.g. acute medical illness, surgery, trauma)

(Raskob, Silverstein, Bratzler, Heit, & White, 2010, Am J Prev Med)

Economic Burden of VTE

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(Mahan, Borrego, Woersching, Federici, Downey, Tiongson, Bieniarz, Cavanaugh, & Spyropoulos, 2012, Thromb Haemost)

Total Cost

Hospital-Acquired

Hospital-Acquired (Preventable)

0 5 10 15 20 25 30

$13.5 - $27.2

$9 -$18.2

$4.5 -$14.2

Dollars in Billions Annually

Incidence of VTE Increases with Age

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Risk of DVT Increases with the Number of Risk Factors

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O’Shaughnessy et al.VERITY Registry Study

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(O'Shaughnessy, Rose, Pressley, Scriven, Farren, Nokes, & Arya, 2006, Blood)

Bahl et al.

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(Bahl, Hu, Henke, Wakefield, Campbell, & Caprini, 2009, Annals of Surg)

Pannucci et al.

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(Pannucci, Bailey, Dreszer, Fisher, Zumsteg, Jaber, Hamill, Hume, Rubin, Neligan, Kallianen, Hoxworth, Pusic, & Wilkins, 2011, J Am Coll Surg)

VTE Risk Factors• Age > 40

• Immobility

• Stroke

• CHF

• Paralysis

• Spinal Cord Injury

• Hyperviscosity

• Polycythemia

• Severe COPD

• Anesthesia

• Obesity

• Varicose veins

• Cancer

• High estrogen states

• Inflammatory bowel

• Nephrotic Syndrome

• Sepsis

• Smoking

• Pregnancy

• Thrombophilia

• Surgery

• Prior VTE

• Central lines

• Trauma

31Most hospitalized patients have at least one risk factor for VTE

Effective, safe, cost effective prevention

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• Cost-effectiveness of VTE prophylaxis has been demonstrated repeatedly

• Primary concern with prophylaxis is bleeding; bleeding secondary to pharmacologic prophylaxis is a rare event

• Concern of heparin induced thrombocytopenia (HIT), incidence of 1% to 5%, uncommon but serious complication

Prevention Strategies reduce VTE by 50-65%

VTE Prophylaxis: A National Priority

• Surgeon General’s Call to Action 2008• AHRQ Top Priority• American Public Health Association (APHA)• NQF endorsed measure• The Joint Commission: Core Measures• CMS EHR Meaningful Use & “never events”• CDC Division of Healthcare Quality and Promotion• National Healthcare Safety Network (NHSN)• Affordable Care Act• HHS: Partnership for Patients

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(TITLE???)

• SCIP• New VTE Core Measures

• VTE – 1 Venous Thromboembolism Prophylaxis

• VTE-2 VTE Prophylaxis ICU• VTE – 6 Incidence of Potentially

Preventable Venous

Thromboembolism34

VTE Prophylaxis in U.S. Hospitals

• Rates of Prophylaxis Remain Low• 40% of US medical patients receive some form of

prophylaxis (ENDORSE)

• 350,000 high risk patients in 376 acute care hospitals (Rothberg, JGIM, 2010)• 36% received prophylaxis by day 2• Only 11% received the usual dosage throughout

the hospitalization• Hospital variation exists: 19%-43%• Only 3% of hospitals had rates > 70% 35

“The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.”

-American Public Health Association (APHA)

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More good news…

“The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.”

- Urbach DR, Baxter NN. BMJ 2005 37

Implementing Performance Improvement

• Develop a multidisciplinary team• Gain institutional buy in & support• Find out your current conditions & develop goals• Use metrics that are reliable & practical• Standardize processes • Consider ease of use• Layer interventions/ methods to increase

reliability • Provide ongoing feedback and refine as

necessary38

Hierarchy of ReliabilityLevel Reliability Strategies Predicted

Prophylaxis Rate

1 No Protocol (“State of Nature”) 40%2 Decision support exists but not linked to order

writing, or prompts within orders but no decision support

50%

3 Protocol well-integrated (into orders at point-of-care)

65-85%

4 Protocol enhanced (by complimentary QI and high reliability strategies)

90%

5 Oversights identified and addressed in real time 95+%

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Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.

High-Reliability Strategies

• Build a “decision aide” or reminder into the system

• Make the desired action the default action • Not doing the desired action requires opting out

• Build redundancy into responsibilities• Schedule steps to occur at known intervals or

events • Standardize a process so that deviation feels

strange• Take advantage of work habits or reliable

patterns of behavior40

Ideal VTE Protocol

1) A standardized VTE risk assessment, linked to…2) A menu of appropriate prophylaxis options, plus…3) A list of contraindications to pharmacologic VTE

prophylaxis

Challenges:Make it mandatory

Make it easy to use (“automatic”)Make sure it applies to all patients

Integrate into clinical workflow & order setsMonitor, tweak, Plan-Do-Check-Act (PDCA)

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Key Strategies

Scope: ALL adult inpatients Standardized VTE Protocol - ACCP as “true

north” Mandatory risk assessment with CPOE hard-stop Clinical decision support to drive clinical practice Required documentation of contraindications

with timed reminders to reassess q24 - 48H Data feedback to services regarding performance VTE prophylaxis included as peer review

(OPPE) indicator for most services Review of EVERY VTE event that occurs in the

health system for preventability

UMHS VTE Effort Timeline 2001-2003: Retrospective data feedback to services

without evidence of improved prophylaxis patterns.

2005: UMHS pilots VTE risk assessment in General Medicine & General Surgery. Paper VTE risk assessment tool.

2007: VTE prophylaxis indicators for physician peer review for 7 services with some improvement noted.

April 2008: CPOE implemented (UM-Carelink) with inclusion of optional electronic VTE risk assessment.

UMHS VTE Effort Timeline (cont.)

October 2008: MEC mandates VTE risk assessment.

January 2009: VTE Committee created & charged by Chief of Staff

March 2009: First VTE Committee meeting, in-depth data analysis begins…

Data is King• Initial focus was on gathering data for group to

analyze• VTE incidence by service (for targeted

interventions)• Global VTE incidence, in-hospital and post-

discharge to 90 days (to track progress)• VTE risk assessment completion by service• VTE risk category by service• VTE prophy patterns with and without R.A.

Figure 1. VTE Risk Assessment Documented in CareLink. Nov. ‘08 thru Feb. ‘09

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Why Risk Assess?

• Multiple studies have shown that we deliver VTE prophylaxis to 50% of patients or less

• There is an under appreciation of VTE risk• In absence of a formal risk assessment, physicians

underestimate risk as much as 50% of times (Holley, Moores, & Jackson, 2005)

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Risk Assessment vs. No Risk AssessmentUMHS Risk Assessment Data

Nov. 2008 – Feb. 2009:

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Prophylaxis- High and Highest-Risk Patients Only

Prophylaxis- All Risk Levels

Prophylaxis- Patients without Risk Assessment

0% 20% 40% 60% 80% 100%

VTE Prophylaxis Rates:Risk Assessment vs. No Risk Assessment

Prophylaxis Received None

Patients with Risk Assessment within 24 hrs:

Of Particular Importance…

• VTE rates are lower in medical patients compared to surgical patients• Important to identify / target the highest risk

• ACCP and ACP guidelines have an increased focus on individualized risk (Lederle, 2011 & Guyatt, 2012)

• CMS and The Joint Commission VTE:• “not at risk or low risk” is a valid reason for

not administering prophylaxis49

Initial Lessons…• Some compliance issues with risk assessment

were due to confusion that completing VTE risk assessment also mandated specific prophylaxis.

• Difficulty finding risk assessment form

• No hard stop within CPOE requiring completion of VTE risk assessment prior to submission of admission orders, but implemented as of June 2009.

• Reminder alerts for VTE assessment were firing nearly 25,000 per month – alert fatigue issue & masking other important alerts

Closing the Gap…• VTE Risk Assessment embedded in all CPOE admission

order sets.

• VTE risk factor reorganization based on Clinical Advisory Group feedback (by risk factor category rather than by points)

• Providers must document clinically appropriate contraindications when deviating from recommendations (this process was improved even further in July 2009).

• Hard stop within CPOE requiring completion of VTE risk assessment prior to admission order submission.

• Service specific data to facilitate discussions51

UMHS Example Caprini Tool

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Prophylaxis recommendation based on risk score

Order Recommended prophylaxis unless contraindicated

Incorporation of VTE order set within admission order sets & hard-stop in June 2009

VTE Assessment vs. UM-CareLink Missing Assessment Reminder Alert

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Achievable and Sustainable

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Keys to Success

• Demonstrated commitment of senior leadership to reducing incidence of VTE

• Institutional will and commitment, even in the face of resistance

• Development of a VTE Committee to oversee effort

• Consensus building process• Know the culture of your organization – culture

is local

Keys to Success

• Clinical champion(s) • Multidisciplinary involvement• Standardized protocols and guidelines• Institutional resources & support, esp. for data

collection & analysis• Multi-modality, multi-level education

• Make it personal – provide real examples from your organization where care was suboptimal

• Nursing buy-in is critical to success

Keys to Success

• VTE Risk Assessment built into existing workflow• Rapid cycle improvement: continuous PDCA &RCA

to trouble shoot problems, evolving circumstances, & improve the process on a continual basis

• Implementation of hard-stop within CPOE to force the function of VTE risk assessment and prophylaxis, plus intelligent design with medical logic modules and clinical decision support to support the desired practice

Summary• Understand regulatory drivers of quality

• Know your hospital’s performance data

• Know your hospital’s patient safety plan

• Key in on your hospital’s goals & identify areas where PAs can make an impact

• Use proven QI strategies63

Summary (cont.)

• Target “low-hanging fruit” • VTE risk assessment/prophylaxis• Improving POA & comorbidity coding• Surgical antibiotic selection/discontinuation• Continuation of perioperative β-blockers

• Clinical Champions – Engage PAs!• PAs can lead QI efforts and achieve

significant results• Providers that can achieve high quality

performance will be increasingly valued64

Additional Resources

• MHA Community Website • http://community.mha.org/Home/

• Society of Hospital Medicine website• http://www.hospitalmedicine.org/

ResourceRoomRedesign/RR_VTE/VTE_Home.cfm

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• Website created to provide an additional resource

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VTE Awareness Websitedontclot.com

Society of Hospital Medicine Resources

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Clinical Tools offers example risk assessment tools and ordersets/ protocols

ReferencesAnderson, F. A., Goldhaber, S. Z., Tapson, V. F. Bergmann, J. F., Kakkar, A. K., Deslandes, B., Huang, W., & Cohen, A. T. (2010). Improving practices in US hospitals to prevent venous thromboembolism: Lessons from ENDORSE. The American Journal of Medicine, 123, 1099-1106.Anderson, F. A., & Spencer, F. A. (2003). Risk factors for venous thromboembolism. Circulation, 107, I-9 – I-16. doi:10.1161/01.CIR.0000078469.07362.E6 Anderson, F. A., Wheeler, H. B., Goldberg, R. J., et al. (1991). A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism:The Worcester DVT Study. Archives of Internal Medicine, 151933–938.Bahl, V., Hu, H. M., Henke, P. K., Wakefield, T. W., Campbell, D. A., & Caprini, J. A. (2009). A validation study of a retrospective venous thromboembolism risk scoring method. Annals of Surgery, 1-7. doi:10.1097/SLA.0b013e31817fca6Beckman, M. G., Hooper, C., Critchley, S. E., & Ortel, T. L. (2010). Venous thromboembolism: A public health concern. American Journal of Preventive Medicine, 38(Suppl4), 495-501.Centers for Disease Control & Prevention, National Center on Birth Defects and Developmental Disabilities, Division of Blood Disorders. (2012). Deep vein thrombosis/ pulmonary emoblism (DVT/PE). Retrieved from http://www.cdc.gov/ncbddd/dvt/ index.html

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ReferencesHeit, J. A. (2008). The epidemiology of venous thromboembolism in the community. Arteriosclerosis Thrombosis and Vascular Biology, 28(3), 370-372. Holley, A. B., Moores, L. K., & Jackson, J. L. (2006). Provider preferences for DVT prophylaxis. Thrombosis Research, 117, 563-568. doi: 10.1016/j.thromre s.2005.04.010Mahan, C. E., Borrego, M. E., Woersching, A. L., Federici, R., Downey, R.,Tiongson, J., Bieniarz, M. C., Cavanaugh, B. J., & Spyropoulos, A. C.(2012). Venous thromboembolism: Annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates. Thrombosis and Haemostais, 108, 291-302. Mahan, C. E., Holdsworth, M. T., Welch, S. M., Borrego, M., & Spyropoulos, A. C. (2011). Deep-vein thrombosis: A United States cost model for a preventable and costly adverse event. Thrombosis Haemostasis, 106, 405-415. Maynard, G., & Stein, J. (2010). Designing and implementing effective venous thromboembolism prevention protocols: Lessons from collaborative efforts. Journal of Thrombosis and Thrombolysis, 29(2), 159-166.O’Shaughnessy, D., Rose, P., Pressley, F., Scriven, N., Farren, T., Nokes, T., & Arya, R. (2006). Evaluating the performance of a previously reported risk score to predict venous thromboembolism: A VERITY registry study. Blood, 108.

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ReferencesPannucci, C. J., Bailey, S. H., Dreszer, G., Fisher, C., Zumsteg, J. W., Jaber, R. M., Hamill, J. B., Hume, K. M., Rubin, J. P., Neligan, P. C., Kallianen, L. K., Hoxworth, R. E., Pusic, A. L., & Wilkins, E. G.(2011). Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. Journal of the American College of Surgeon, 212(1),105-112. doi: 10.1016/j.jamcollsurg.2010.08.018Raskob, G. E., Silverstein, R., Bratzler, D. W., Heit, J. A., & White, R. H. (2010). Surveillance for deep vein thrombosis and pulmonary embolism: Recommendations from a national workshop. American Journal of Preventive Medicine, 38(4S), 502-509.Rothberg, M. B., Lahti, M., Pekow, P. S., & Lindenauer, P. K. (2010). Venous thromboembolism prophylaxis among medical patients at US hospitals. Journal of General Internal Medicine, 25(6), 489-494.

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Caprini, J. A. (2005). Thrombosis risk assessment as a guide to quality patient care. Disease-a-Month, 51(2-3), 70-78. doi: 10.1016/j.disamonth.2005.02.003Caprini, J. A., Arcelus, Treverso, C. I. et al. (1991). Clinical assessment of venous thromboembolic risk in surgical patients. Seminars in Thrombosis and Hemostasis. 17(suppl 3), 304-312.

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