VTE Prophylaxis in VTE Prophylaxis in the Hospitalized the Hospitalized

Patient: Patient: Importance and Importance and Strategies for Strategies for

Improved Improved ComplianceComplianceAndrew H. Dombro, M.D.Andrew H. Dombro, M.D.

Instructor of MedicineInstructor of MedicineDivision of General Internal Medicine, Hospital Division of General Internal Medicine, Hospital

Medicine SectionMedicine SectionUniversity of Colorado Health Sciences CenterUniversity of Colorado Health Sciences Center

OverviewOverview

Background / Prevalence of VTEBackground / Prevalence of VTE Benefits / Rationale for VTE prophylaxisBenefits / Rationale for VTE prophylaxis Identification of hospitalized patients most Identification of hospitalized patients most

at riskat risk Methods of VTE prophylaxisMethods of VTE prophylaxis National Consensus Standards for National Consensus Standards for

Prevention and Care of VTE (CMS as well?)Prevention and Care of VTE (CMS as well?) Factors related to under-use of established Factors related to under-use of established

guidelines guidelines Strategies to improve complianceStrategies to improve compliance

Background / Prevalence of Background / Prevalence of VTEVTE

PE is responsible for up to PE is responsible for up to 200K deaths per year in the 200K deaths per year in the United StatesUnited States¹¹

PE remains the most common PE remains the most common preventablepreventable cause of hospital cause of hospital death, accounting for up to death, accounting for up to 10%²10%²

DVT/PE is DVT/PE is muchmuch more common more common in the hospitalized patient -- in the hospitalized patient -- medical and surgical³medical and surgical³

1. Horlander, KT, Mannino, DM, Leeper, KV. 1. Horlander, KT, Mannino, DM, Leeper, KV. Arch Intern MedArch Intern Med 2003; 163:1711 2003; 163:17112. Pendleton R et al. Am J Hemat. 2005;79:229-237.3. Edelsberg J et al. Am J Health Syst Pharm 2006; 63: 16S-22S

Background / PrevalenceBackground / Prevalence

VTE is more than 130 times greater VTE is more than 130 times greater among among hospitalizedhospitalized patients than patients than community residentscommunity residents¹¹ half of community-based cases nursing half of community-based cases nursing

home patients home patients oror within 90 days of within 90 days of hospital discharge hospital discharge

60% of all cases occurred in either 60% of all cases occurred in either hospitalized, recently d/c’d, or NH hospitalized, recently d/c’d, or NH patients!patients!

Hospitalization for acute Hospitalization for acute medicalmedical illnessillness is associated with up to an is associated with up to an 8-8-fold increasefold increase in relative risk for VTE in relative risk for VTE

1. Heit, JA, Melton, LJ, Lohse, CM, et al. 1. Heit, JA, Melton, LJ, Lohse, CM, et al. Mayo Clin ProcMayo Clin Proc 2001; 76: 1102 2001; 76: 1102

Background / PrevalenceBackground / Prevalence Death occurs in about 6% of DVT cases within Death occurs in about 6% of DVT cases within

one month of diagnosisone month of diagnosis11

Death occurs in about 12% of PE cases within Death occurs in about 12% of PE cases within one month of diagnosisone month of diagnosis11

Up to 25% of distal DVT can propagate into Up to 25% of distal DVT can propagate into proximal DVTproximal DVT²²

Pulmonary emboli are detected in approximately Pulmonary emboli are detected in approximately 50% of patients with proximal DVT50% of patients with proximal DVT²²

Recurrent DVT:Recurrent DVT: Can occur in 30% of DVT patients within 10 Can occur in 30% of DVT patients within 10

years after initial treatment³years after initial treatment³

1. American Heart Association. Heart Disease and Stroke Statistics – 2005 Update.2. Anand, SA et al. JAMA. 1998;279:1094-1099.3. Prandoni P et al. Haemotologia 2007; 92: 199-205

Background / Background / Prevalence¹Prevalence¹

Without prophylaxisWithout prophylaxis, overall , overall DVTDVT incidence in hospitalized medical and incidence in hospitalized medical and general surgical patients is 10-40% general surgical patients is 10-40% 40-60% following major orthopedic surgery40-60% following major orthopedic surgery

Without prophylaxis,Without prophylaxis, fatal PEfatal PE occurs occurs with the following frequency in with the following frequency in hospitalized patients:hospitalized patients: 0.1-0.8% undergoing elective general 0.1-0.8% undergoing elective general

surgerysurgery 2-3% undergoing elective hip replacement2-3% undergoing elective hip replacement 4-7% undergoing surgery for fractured hip!4-7% undergoing surgery for fractured hip!

1. 1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S

Background / PrevalenceBackground / Prevalence

Without prophylaxis, reported VTE occurrence Without prophylaxis, reported VTE occurrence in the ICU ranges between <10% to nearly in the ICU ranges between <10% to nearly 100%!!100%!! Virtually Virtually allall critical care patients are at moderate to critical care patients are at moderate to

high riskhigh risk Up to 10% to 15% of patients with cancer may develop Up to 10% to 15% of patients with cancer may develop

a VTEa VTE11

Malignancy independent factor for decreased early Malignancy independent factor for decreased early and late survival after VTE eventand late survival after VTE event²²

1. Viale PH, Schwartz RN. Clin J Onco Nurs. 2004;8:455-461.2. Heit JA et al. Arch Intern Med. 1999;159:445-453

Consequences of Consequences of Unprevented VTEUnprevented VTE

Fatal PE Fatal PE -- usually occurs without warning and often -- usually occurs without warning and often with no potential to resuscitate¹with no potential to resuscitate¹

Patient discomfortPatient discomfort associated with VTE associated with VTE Initial pain and discomfortInitial pain and discomfort Post-thrombotic syndrome (PTS)²Post-thrombotic syndrome (PTS)² Chronic Thromboembolic Pulmonary Chronic Thromboembolic Pulmonary

Hypertension (CTPH)³Hypertension (CTPH)³ $$$$ spent in the investigation of suspected and spent in the investigation of suspected and

treatment of documented VTEtreatment of documented VTE Risk of treatmentRisk of treatment once VTE occurs once VTE occurs Increased Increased length of length of initialinitial hospital stay hospital stay More frequent hospital More frequent hospital readmissionreadmission Increased Increased future riskfuture risk of VTE of VTE (4)(4)

1. Anderson FA et al. 1. Anderson FA et al. Arch Intern MedArch Intern Med 1991; 151: 933-8 1991; 151: 933-82. Büller, HR et al. Chest. 2004;126:4018-4288.3. Pengo V et al. N EnglJ Med. 2004;350:2257-2264.4. Heit JA et al. Arch Intern Med 2000; 160:761-8

Benefits / Rationale of VTE Benefits / Rationale of VTE ProphylaxisProphylaxis

DVT and PE are prevalent and serious DVT and PE are prevalent and serious complicationscomplications11

Difficult to predict with any certainty which Difficult to predict with any certainty which patients will develop VTEpatients will develop VTE²²

Patients can experience VTE weeks after Patients can experience VTE weeks after surgerysurgery22

Clinical consequences of VTE, including Clinical consequences of VTE, including mortality, are commonmortality, are common33

Health burden associated with VTE is expected Health burden associated with VTE is expected to grow dramatically during coming years, in to grow dramatically during coming years, in part due to aging population part due to aging population (4)(4)

1. 1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S.2. White RH et al. Arch Intern Med. 1998;158:1525-1531.3. Pengo V et al. N Engl J Med. 2004;350:2257-2264.4. Stein PQ et al. 4. Stein PQ et al. Arch Intern MedArch Intern Med 2004. 164:2260-65 2004. 164:2260-65

Benefits / Rationale of VTE Benefits / Rationale of VTE Prophylaxis¹Prophylaxis¹

Hospital-acquired DVT/PE is Hospital-acquired DVT/PE is usuallyusually clinically silent --clinically silent --oonly 1/3 present with nly 1/3 present with classic symptoms²classic symptoms²

Overall incidence likely underestimated³Overall incidence likely underestimated³ Screening, either by physical exam or Screening, either by physical exam or

noninvasive testing, is not clinically effective noninvasive testing, is not clinically effective or cost effectiveor cost effective

Prophylaxis is far more effective for Prophylaxis is far more effective for preventing death/morbidity from VTE than preventing death/morbidity from VTE than is treatment of established diseaseis treatment of established disease

1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S2. Turkstra F et al. Ann Intern Med 1997; 126: 775-813. Kyrle PA et al. Lancet 2005; 365: 1163-74

Benefits / Rationale of VTE Benefits / Rationale of VTE prophylaxisprophylaxis

Effective and safe prophylactic measures are Effective and safe prophylactic measures are available for most high-risk patients available for most high-risk patients (1,2)(1,2)

pharmacologic prophylaxis lowers the risk of pharmacologic prophylaxis lowers the risk of symptomatic and asymptomatic VTE in symptomatic and asymptomatic VTE in medical patients by 50%-75%!medical patients by 50%-75%!

little or no increase in rates of clinically little or no increase in rates of clinically important bleeding complicationsimportant bleeding complications

Based on solid principles and scientific Based on solid principles and scientific evidence from large numbers of randomized evidence from large numbers of randomized clinical trials³clinical trials³

Most hospitalized patients have one or more Most hospitalized patients have one or more risk factor for VTE – and importantly, these are risk factor for VTE – and importantly, these are cumulativecumulative(4)(4)

1. Gerotziafas, GT, Samama, MM. 1. Gerotziafas, GT, Samama, MM. Curr Opin Pulm MedCurr Opin Pulm Med 2004; 10:356 2004; 10:3562. Clagett, GP, Reisch, JS. 2. Clagett, GP, Reisch, JS. Ann SurgAnn Surg 1988; 208:227 1988; 208:2273. Patel R et al. 3. Patel R et al. J Crit CareJ Crit Care 2005; 20:34-7 2005; 20:34-74. Dorfman, et al. 4. Dorfman, et al. J Clin Pharm TherapJ Clin Pharm Therap 2006; 31: 455-9 2006; 31: 455-9

Benefits of VTE Benefits of VTE ProphylaxisProphylaxis

Appropriate VTE Appropriate VTE prophylaxis prophylaxis achieves two very achieves two very desirable results:desirable results: Improved patient Improved patient

outcomesoutcomes Reduced costsReduced costs

No No definitivedefinitive way to predict which way to predict which patients will acquire VTEpatients will acquire VTE11

Risk factors for VTE have been Risk factors for VTE have been reportedreported1,21,2

Preexisting and surgical risk factors for Preexisting and surgical risk factors for VTE can be cumulative for patients VTE can be cumulative for patients undergoing surgeryundergoing surgery33

Patients undergoing hip or knee Patients undergoing hip or knee replacement or hip fracture surgery are replacement or hip fracture surgery are among those at highest riskamong those at highest risk11

1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S.2. Heit JA et al Arch Intern Med. 2000;160:809-815.3. Geerts WH, et al. Chest. 2001;119:132S-175S.

Risk Factors: Predicting Risk Factors: Predicting VTEVTE

VTE Risk: Medical and VTE Risk: Medical and Surgical Patient Surgical Patient

Characteristics Characteristics (1,2)(1,2) History of VTEHistory of VTE Family history VTEFamily history VTE MalignancyMalignancy Increased age (possibly Increased age (possibly ≥ ≥

41)41) CHFCHF AMIAMI Ischemic CVAIschemic CVA Pregnancy/PostpartumPregnancy/Postpartum Infection/SepsisInfection/Sepsis Prolonged immobilizationProlonged immobilization Acute/chronic lung diseaseAcute/chronic lung disease Hypotension/shockHypotension/shock

Inflammatory disease Inflammatory disease (including IBD)(including IBD)

Estrogen therapyEstrogen therapy Obesity (BMI>25)Obesity (BMI>25) Tobacco useTobacco use Varicose veinsVaricose veins Inhibitor deficiency statesInhibitor deficiency states

Antiphospholipid Ab’sAntiphospholipid Ab’s Protein C/SProtein C/S Factor V Leiden (3-7%)Factor V Leiden (3-7%) Prothrombin Gene Prothrombin Gene

Mutation (2%)Mutation (2%) AT IIIAT III

1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S; Heit JA et al. Arch Intern Med. 2000;160:809-815.2. Kikura, M, Takada, T, Sato, S. Preexisting morbidity as an independent risk factor for perioperative acute2. Kikura, M, Takada, T, Sato, S. Preexisting morbidity as an independent risk factor for perioperative acute thromboembolism syndrome. Arch Surg 2005; 140:1210thromboembolism syndrome. Arch Surg 2005; 140:1210

Surgical Risk FactorsSurgical Risk Factors

ProcedureProcedure Surgical siteSurgical site Surgical techniqueSurgical technique AnestheticAnesthetic Duration of procedureDuration of procedure Presence of infectionPresence of infection Postoperative immobilizationPostoperative immobilization

Virchow’s TriadVirchow’s Triad¹¹

Vascular InjuryVascular Injury²²

Recurrent DVT/PERecurrent DVT/PESurgerySurgery

Cancer treatmentCancer treatmentTraumaTrauma

Venipuncture Venipuncture AtherosclerosisAtherosclerosis

IV drug IV drug administrationadministration

Risk Factors are Cumulative3

1. Anderson, FA et al. Circulation.2003;107:I-9--I-10.2. Viale PH, Schwartz RN. Clin J Onco Nurs. 2004;8:455-461.3. Rosendaal FR. Lancet. 1999;353:1167-1173.

Hypercoaguable State2

Hereditary risk factorsBleeding disorders

Malignancy

Venous Stasis²

ObesityImmobility

Chronic heart diseaseAge above 40

Extended VTE Risk Extended VTE Risk Following Hospital Following Hospital

DischargeDischarge VTE can occur for up to 3 months after total VTE can occur for up to 3 months after total

knee and hip arthroplastyknee and hip arthroplasty11

Hypercoagulability can persist for 6 weeks Hypercoagulability can persist for 6 weeks after hip fractureafter hip fracture22

Venous function was significantly impaired for Venous function was significantly impaired for up to 42 days following hip fracture surgeryup to 42 days following hip fracture surgery33

Recurrent DVT:Recurrent DVT: 30% of DVT patients 8 to 10 years after 30% of DVT patients 8 to 10 years after

initial treatmentinitial treatment44

1. White RH et al. Arch Intern Med. 1998;158:1525-1531.2. Wilson D et al. Injury. 2001;32:765-770.3. Wilson D et al. Injury. 2002;33:33-39.4. American Heart Association. Heart Disease and Stroke Statistics – 2005 Update.

Features of an Ideal VTE Features of an Ideal VTE Prophylaxis RegimenProphylaxis Regimen

EffectiveEffective SafeSafe Good complianceGood compliance Easily administeredEasily administered No laboratory monitoring neededNo laboratory monitoring needed Cost effectiveCost effective

Methods of VTE Methods of VTE ProphylaxisProphylaxis

Mechanical:Mechanical: Graduated Compression Stockings Graduated Compression Stockings

(GCS)(GCS) Intermittent Pneumatic Compression Intermittent Pneumatic Compression

Devices (IPC)Devices (IPC)

PharmacologicPharmacologic

Mechanical ProphylaxisMechanical Prophylaxis

AdvantagesAdvantages Lack of bleeding Lack of bleeding

potentialpotential11

No clinically important No clinically important side effectsside effects

No laboratory monitoring No laboratory monitoring neededneeded22

IPC stimulates IPC stimulates endogenous fibrinolytic endogenous fibrinolytic activity (ractivity (reduces educes plasminogen activator plasminogen activator inhibitor-1 levels by inhibitor-1 levels by unknown mechanism) unknown mechanism) 22

DisadvantagesDisadvantages No mechanical prophylaxis No mechanical prophylaxis

options have been shown to options have been shown to reduce the risk of death or reduce the risk of death or PEPE11

Must be worn continuously: Must be worn continuously: pre-, intra- and pre-, intra- and postoperatively for 72 postoperatively for 72 hourshours1 1

GCS can cause impairment GCS can cause impairment in tissue oxygenation (PVD)in tissue oxygenation (PVD)33

GCS need to be sized and GCS need to be sized and fitted properlyfitted properly33

1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S.2. Davis P. J Ortho Nurs. 2004;8:50-56. 3. Agu O et al. Br J Surg. 1999;86:992-1004.

Pharmacologic ProphylaxisPharmacologic Prophylaxis

Aspirin – NOT recommended as sole prophylaxis Aspirin – NOT recommended as sole prophylaxis agentagent11

Low-dose unfractionated heparin (LDUH)Low-dose unfractionated heparin (LDUH)22

Low molecular weight heparin (LMWH)Low molecular weight heparin (LMWH)22

EnoxaparinEnoxaparin DalteparinDalteparin TinzaparinTinzaparin

Vitamin K antagonist (VKA)Vitamin K antagonist (VKA)11

WarfarinWarfarin Factor Xa inhibitorFactor Xa inhibitor22

FondaparinuxFondaparinux

Choice of pharmacologic agent depends on VTE risk reduction, complication rate and proper dosing of agent2

1. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S. 2. Pendleton R et al. Am J Hemat. 2005;79:229-237.

Risky BusinessRisky Business The majority of hospitalized medical The majority of hospitalized medical

andand surgical patients are at increased surgical patients are at increased risk of VTE²risk of VTE²

Risks appear to be cumulative¹Risks appear to be cumulative¹ Risk Risk stratificationstratification is cumbersome, not is cumbersome, not

adequately validated, and therefore not adequately validated, and therefore not as widely agreed-upon in as widely agreed-upon in medicalmedical patients as in surgical patientspatients as in surgical patients

Guidelines, however, do exist Guidelines, however, do exist (2,3)(2,3)

1. Dorfman, et al. 1. Dorfman, et al. J Clin Pharm TherapJ Clin Pharm Therap 2006; 31: 455-9 2006; 31: 455-92. Edelsberg, J et al. 2. Edelsberg, J et al. Am J Health-Syst PharmAm J Health-Syst Pharm 2006. 63: S16-S22 2006. 63: S16-S223. Geerts WH et al. Chest. 2004;126(3 suppl):338S-400S.

ACCP Recommendations ACCP Recommendations (since 1986)(since 1986)

Geerts, WH, Geerts, WH, et al.et al. CHESTCHEST 2004; 126: 2004; 126: 338s-400s338s-400s

VTE Prophylaxis UsageVTE Prophylaxis Usage Varies markedly, overall remaining abysmally lowVaries markedly, overall remaining abysmally low

Audit of 384 patients with VTEAudit of 384 patients with VTE¹¹:: 201 (52%) received prophylaxis 201 (52%) received prophylaxis

(112 anticoagulation, 31 mechanical prophylaxis, 58 combination)(112 anticoagulation, 31 mechanical prophylaxis, 58 combination) 183 (48%) No prophylaxis183 (48%) No prophylaxis 13 deaths due to PE13 deaths due to PE

One study showed that One study showed that only 46%only 46% of hospitalized medical of hospitalized medical patients, with risk factors for VTE, received appropriate patients, with risk factors for VTE, received appropriate prophylaxis²prophylaxis²

Various studies show a VTE prophylaxis rate in surgical Various studies show a VTE prophylaxis rate in surgical patients varying from 38% to 94% patients varying from 38% to 94% (3,4)(3,4)

true even amongst orthopedic surgeons³true even amongst orthopedic surgeons³

1. Goldhaber et al. Chest 2000:118:1680-1684.

2. Ageno et al. Haematologia 2002; 87: 746-50

3. Stratton et al. Arch Intern Med 2000; 160: 334-40

4.Anderson et al. J Thromb Thrombol 1998; 5: S7-S11

VTE Prophylaxis UsageVTE Prophylaxis Usage Even when used, guideline Even when used, guideline

recommendations often not followedrecommendations often not followed Grade IA ACCP recommendations were Grade IA ACCP recommendations were

followed from 45% (hip fracture surgery) followed from 45% (hip fracture surgery) to 84% (elective THR) of the time¹to 84% (elective THR) of the time¹

Retrospective study – overall compliance Retrospective study – overall compliance rate 13.3% in greater than 120,000 rate 13.3% in greater than 120,000 hospital admissions²hospital admissions²

2.8% Neurosurgery2.8% Neurosurgery 52.4 % Orthopedic Surgery52.4 % Orthopedic Surgery 13.3 % Medicine13.3 % Medicine

1. Statton et al. 1. Statton et al. Arch Intern MedArch Intern Med 2000; 160: 334-40 2000; 160: 334-402. Yu HT et al. 2. Yu HT et al. Am J Health Syst PharmAm J Health Syst Pharm 2007. 64: 69-76 2007. 64: 69-76

VTE Prophylaxis UsageVTE Prophylaxis Usage

HospitalistsHospitalists found superior!¹ found superior!¹ Pneumonia Care + VTE prophylaxisPneumonia Care + VTE prophylaxis 96.0% vs. 61.9%96.0% vs. 61.9%

1. William D et al. 1. William D et al. Am J Manag CareAm J Manag Care 2007. 13:129-32 2007. 13:129-32

Contributing Factors to Contributing Factors to Under Use – Physician Under Use – Physician

Related Related (1,2)(1,2)

Lack of awareness / unfamiliarity with Lack of awareness / unfamiliarity with guidelinesguidelines

Perception that VTE is not a significant or Perception that VTE is not a significant or frequent problemfrequent problem

Patients will be ambulatory “soon enough”Patients will be ambulatory “soon enough” Concern over bleeding risks (surgical sites Concern over bleeding risks (surgical sites

and elsewhere)and elsewhere) Guidelines seem complicated or difficult to Guidelines seem complicated or difficult to

applyapply Patients so ill on admission that VTE Patients so ill on admission that VTE

concerns don’t “hit the radar screen”concerns don’t “hit the radar screen” More difficult to More difficult to changechange habits than to habits than to

incorporate a incorporate a newnew habit habit1. Geerts et al. 1. Geerts et al. ChestChest 2004; 126: 338S-400S 2004; 126: 338S-400S2. Cabana et al. 2. Cabana et al. JAMAJAMA 1999; 282: 1458-65 1999; 282: 1458-65

Contributing Factors to Contributing Factors to Under use -- Under use --

Environmental¹Environmental¹ Not under physicians’ direct control, Not under physicians’ direct control,

such as acquisition of new resources or such as acquisition of new resources or facilitiesfacilities

Lack of timeLack of time Financial constraints (increased Financial constraints (increased

practice costs, lack of reimbursement)practice costs, lack of reimbursement) Increased legal liabilityIncreased legal liability

1. Cabana et al. JAMA 1999; 282: 1458-651. Cabana et al. JAMA 1999; 282: 1458-65

Contributing Factors to Contributing Factors to Under Use – Institution Under Use – Institution

Related¹Related¹ Lack of standardized order sets for Lack of standardized order sets for

VTE prophylaxisVTE prophylaxis Lack of user-friendly patient risk Lack of user-friendly patient risk

assessment tools/mechanismsassessment tools/mechanisms Logistical limitations of health care Logistical limitations of health care

management systems, for instance management systems, for instance lack of medical informatics systems lack of medical informatics systems with computerized “prompts”with computerized “prompts”

1. Cabana et al. JAMA 1999; 282: 1458-651. Cabana et al. JAMA 1999; 282: 1458-65

National Consensus National Consensus Standards for Prevention Standards for Prevention

and Care of VTEand Care of VTE JCAHO and National Quality Forum (NQF) JCAHO and National Quality Forum (NQF)

-- project began 9/04-- project began 9/04 Eight different measures have been Eight different measures have been

recommended by the Technical Advisory recommended by the Technical Advisory Panel (TAP) for pilot testing this year. Panel (TAP) for pilot testing this year. Regarding VTE prophylaxis, these include:Regarding VTE prophylaxis, these include: VTE Risk Assessment (RA)/Prophylaxis within VTE Risk Assessment (RA)/Prophylaxis within

24 hours of hospital admission24 hours of hospital admission VTE Risk Assessment (RA)/Prophylaxis within VTE Risk Assessment (RA)/Prophylaxis within

24 hours of transfer to ICU24 hours of transfer to ICU Incidence of Potentially Preventable Hospital-Incidence of Potentially Preventable Hospital-

acquired VTEacquired VTE

Center for Medicare and Center for Medicare and Medicaid ServicesMedicaid Services

CMS is strongly considering using CMS is strongly considering using VTE prophylaxis as a core safety VTE prophylaxis as a core safety compliance and performance compliance and performance measuremeasure This will directly affect hospital / This will directly affect hospital /

physician reimbursements (i.e., pay for physician reimbursements (i.e., pay for performance)performance)

The Literature – What Has The Literature – What Has Worked?Worked?

Respected leaders within institutions¹Respected leaders within institutions¹ Clinical audits with Clinical audits with feedback feedback (2,3)(2,3)

Clinical decision support tools (83% → 95%) Clinical decision support tools (83% → 95%) (4)(4)

Clinical guidelines combined with chart Clinical guidelines combined with chart monitoring monitoring (5)(5)

Nursing/patient education for increased Nursing/patient education for increased compliance with SCD’s compliance with SCD’s (6)(6)

Establishment of protocols, combined with staff Establishment of protocols, combined with staff education and a daily computer driven reminder education and a daily computer driven reminder (reporting tool) for morning rounds in ICU (reporting tool) for morning rounds in ICU (7)(7)

Computer based reminders Computer based reminders (8)(8)

1. Winkler, et al. 1. Winkler, et al. Arch Intern MedArch Intern Med 1985; 145:314-7 1985; 145:314-72. Williams, et al. 2. Williams, et al. Ann R Coll Surg EnglAnn R Coll Surg Engl 1997; 79:55-7 1997; 79:55-73. Greco, et al. 3. Greco, et al. NEJMNEJM 1993; 329: 1271-4 1993; 329: 1271-44. Durieux, et al. 4. Durieux, et al. JAMAJAMA 2000; 283: 2816-21 2000; 283: 2816-215. Phillips, et al. 5. Phillips, et al. Thromb HaemostThromb Haemost 1997; 77: 283-8 1997; 77: 283-86. Stewart, D et al. 6. Stewart, D et al. Ann SurgAnn Surg 2006. 72: 921-3 2006. 72: 921-37. Wahl, WL et al. 7. Wahl, WL et al. Surgery Surgery 2006. 140: 648-92006. 140: 648-98. Patterson R. Proc 8. Patterson R. Proc AMIA SympAMIA Symp 1998. 573-6 1998. 573-6

Future Directions -- UCHSCFuture Directions -- UCHSC

Increase overall VTE prophylaxis Increase overall VTE prophylaxis compliancecompliance

Improved methods of risk Improved methods of risk stratificationstratification

Increased adherence to established Increased adherence to established guidelinesguidelines

Proposed results:Proposed results: Improved patient safety and outcomesImproved patient safety and outcomes Improved adherence to JHACO / CMS Improved adherence to JHACO / CMS

standards and institutionally standards and institutionally established compliance targets/goalsestablished compliance targets/goals

Proposed Study - UCHSCProposed Study - UCHSC

Prospective historical controlled trialProspective historical controlled trial Develop simple, useable method of VTE Develop simple, useable method of VTE

risk stratificationrisk stratification Utilize prompts – written and eventually Utilize prompts – written and eventually

electronicelectronic Measure compliance rates compared to Measure compliance rates compared to

historic rateshistoric rates

MethodsMethods Using established risk factors, develop simple, Using established risk factors, develop simple,

useable method of risk stratifications for useable method of risk stratifications for clinicians, using methods that have proved clinicians, using methods that have proved effective¹effective¹ Initially paper admission/transfer ordersInitially paper admission/transfer orders With CPOE, add as “pop-up”²With CPOE, add as “pop-up”² Include current ACCP guidelinesInclude current ACCP guidelines

Use medication reconciliation sheets/orders as Use medication reconciliation sheets/orders as reminderreminder Forms would be mandatory for all Forms would be mandatory for all

admissions/transfersadmissions/transfers Again, with CPOE, would be contained thereinAgain, with CPOE, would be contained therein

Measure rates of physician compliance and Measure rates of physician compliance and choice of method on high-risk patients (2 or choice of method on high-risk patients (2 or more risk factors) pre and post implementationmore risk factors) pre and post implementation

1. McCaffrey R et al. 1. McCaffrey R et al. Worldviews Evid Based NursWorldviews Evid Based Nurs 2007; 4:14-20 2007; 4:14-202. Paterno MD et al. 2. Paterno MD et al. AMIA Annu Symp ProcAMIA Annu Symp Proc 2006; 1058 2006; 1058

General ConclusionsGeneral Conclusions VTE prophylaxis is justified, low-risk, and VTE prophylaxis is justified, low-risk, and

indicated in indicated in mostmost hospitalized patients hospitalized patients Good for patientsGood for patients Good for hospitalsGood for hospitals

Overall, VTE prophylaxis is under-utilizedOverall, VTE prophylaxis is under-utilized Hospitals and physicians will soon be judged on Hospitals and physicians will soon be judged on

compliancecompliance Each hospital needs a Each hospital needs a standardizedstandardized approach for approach for

VTE prophylaxis to improve complianceVTE prophylaxis to improve compliance protocols, pre-printed orders, risk stratification, etc.protocols, pre-printed orders, risk stratification, etc. Multi-disciplinary approachMulti-disciplinary approach auditingauditing

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