Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: a quasi-experimental study
Venous thromboembolism (VTE) causes morbidity and mortality in hospitalized patients, and regulators and payors are encouraging the use of systems to prevent them. Here, we examine the effect of a computerized clinical decision support (CDS) intervention implemented across a multi-hospital academic health system on VTE prophylaxis and events.
The study included 223,062 inpatients admitted between April 2007 and May 2010, and used administrative and clinical data. The intervention was integrated into a commercial electronic health record (EHR) in an admission orderset used for all admissions. Three time periods were examined: baseline (period 1), and the time after implementation of the first CDS intervention (period 2) and a second iteration (period 3). Providers were prompted to accept or decline prophylaxis based on patient risk. Time series analyses examined the impact of the intervention on VTE prophylaxis during time periods two and three compared to baseline, and a simple pre-post design examined impact on VTE events and bleeds secondary to anticoagulation. VTE prophylaxis and events were also examined in a prespecified surgical subset of our population meeting the public reporting criteria defined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI).
Unadjusted analyses suggested that “recommended”, “any”, and “pharmacologic” prophylaxis increased from baseline to the last study period (27.1% to 51.9%, 56.7% to 78.1%, and 42.0% to 54.4% respectively; p < 0.01 for all comparisons). Results were significant across all hospitals and the health system overall. Interrupted time series analyses suggested that our intervention increased the use of “recommended” and “any” prophylaxis by 7.9% and 9.6% respectively from baseline to time period 2 (p < 0.01 for both comparisons); and 6.6% and 9.6% respectively from baseline to the combined time periods 2 and 3 (p < 0.01 for both comparisons). There were no significant changes in “pharmacologic” prophylaxis in the adjusted model. The overall percent of patients with VTE increased from baseline to the last study period (2.0% to 2.2%; p = 0.03), but an analysis excluding patients with VTE “present on admission” (POA) demonstrated no difference in events (1.3% to 1.3%; p = 0.80). Overall bleeds did not significantly change. An analysis examining VTE prophylaxis and events in a surgical subset of patients defined by the AHRQ PSI demonstrated increased “recommended”, “any”, and “pharmacologic” prophylaxis from baseline to the last study period (32.3% to 60.0%, 62.8% to 85.7%, and 47.9% to 63.3% respectively; p < 0.01 for all comparisons) as well as reduced VTE events (2.2% to 1.7%; p < 0.01).
The CDS intervention was associated with an increase in “recommended” and “any” VTE prophylaxis across the multi-hospital academic health system. The intervention was also associated with increased VTE rates in the overall study population, but a subanalysis using only admissions with appropriate POA documentation suggested no change in VTE rates, and a prespecified analysis of a surgical subset of our sample as defined by the AHRQ PSI for public reporting purposes suggested reduced VTE. This intervention was created in a commonly used commercial EHR and is scalable across institutions with similar systems.
- Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW: Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008, 133:381S-453S. CrossRef
- Lederle FA, Zylla D, MacDonald R, Wilt TJ: Venous thromboembolism prophylaxis in hospitalized medical patients and those with stroke: a background review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2011,155(9):602–615.
- Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr: Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012, 141:e278S-e325S. CrossRef
- Michota F, Connor PJ, McKean SC, Deitelzweig SB, Sasahara A, Jacobson A: Improving thromboprophylaxis: performance measures and practical strategies. J Hosp Med 2009, 4:S24-S30. CrossRef
- Pronovost PJ, Goeschel CA, Wachter RM: The wisdom and justice of not paying for "preventable complications". JAMA 2008,299(18):2197–2199. CrossRef
- Tooher R, Middleton P, Pham C, Fitridge R, Rowe S, Babidge W, Maddern G: A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 2005,241(3):397–415. CrossRef
- Baroletti S, Munz K, Sonis J, Fanikos J, Fiumara K, Paterno M, Goldhaber SZ: Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study. J Thromb Thrombolysis 2008,25(2):146–150. CrossRef
- Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E: A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. JAMA 2000,283(21):2816–2821. CrossRef
- Fiumara K, Piovella C, Hurwitz S, Piazza G, Niles CM, Fanikos J, Paterno M, Labreche M, Stevens LA, Baroletti S, Goldhaber SZ: Multi-screen electronic alerts to augment venous thromboembolism prophylaxis. Thromb Haemost 2010,103(2):312–317. CrossRef
- Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ: Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005,352(10):969–977. CrossRef
- Mosen D, Elliott CG, Egger MJ, Mundorff M, Hopkins J, Patterson R, Gardner RM: The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism. Chest 2004,125(5):1635–1641. CrossRef
- Novis SJ, Havelka GE, Ostrowski D, Levin B, Blum-Eisa L, Prystowsky JB, Kibbe MR: Prevention of thromboembolic events in surgical patients through the creation and implementation of a computerized risk assessment program. J Vasc Surg 2010,51(3):648–654. CrossRef
- Piazza G, Rosenbaum EJ, Pendergast W, Jacobson JO, Pendleton RC, McLaren GD, Elliott CG, Stevens SM, Patton WF, Dabbagh O, Paterno MD, Catapane E, Li Z, Goldhaber SZ: Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients. Circulation 2009,119(16):2196–2201. CrossRef
- Galanter WL, Thambi M, Rosencranz H, Shah B, Falck S, Lin FJ, Nutescu E, Lambert B: Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital. Am J Health Syst Pharm 2010,67(15):1265–1273. CrossRef
- Lecumberri R, Marques M, Diaz-Navarlaz MT, Panizo E, Toledo J, Garcia-Mouriz A, Paramo JA: Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients. Thromb Haemost 2008,100(4):699–704.
- Sobieraj DM: Development and implementation of a program to assess medical patients' need for venous thromboembolism prophylaxis. Am J Health Syst Pharm 2008,65(18):1755–1760. CrossRef
- Maynard GA, Morris TA, Jenkins IH, Stone S, Lee J, Renvall M, Fink E, Schoenhaus R: Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med 2010,5(1):10–18.
- Isaac T, Weissman JS, Davis RB, Massagli M, Cyrulik A, Sands DZ, Weingart SN: Overrides of medication alerts in ambulatory care. Arch Intern Med 2009,169(3):305–311. CrossRef
- Umscheid CA, Williams K, Brennan PJ: Hospital-based comparative effectiveness centers: translating research into practice to improve the quality, safety and value of patient care. J Gen Int Med 2010,25(12):1352–1355. CrossRef
- Agency for Healthcare Research and Quality. 2012. [Guide to Patient Safety Indicators] http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx.
- Arnason T, Wells PS, Walraven C, Forster AJ: Accuracy of coding for possible warfarin complications in hospital discharge abstracts. Thromb Res 2006,118(2):253–262. CrossRef
- Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D: Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002,27(4):299–309. CrossRef
- Couban S, Goodyear M, Burnell M, Dolan S, Wasi P, Barnes D, Macleod D, Burton E, Andreou P, Anderson DR: Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 2005,23(18):4063–4069. CrossRef
- Monreal M, Alastrue A, Rull M, Mira X, Muxart J, Rosell R, Abad A: Upper extremity deep venous thrombosis in cancer patients with venous access devices–prophylaxis with a low molecular weight heparin (Fragmin). Thromb Haem 1996,75(2):251–253.
- Ruud E, Holmstrom H, De Lange C, Hogstad EM, Wesenberg F: Low-dose warfarin for the prevention of central line-associated thromboses in children with malignancies–a randomized, controlled study. Acta Paediatr 2006,95(9):1053–1059. CrossRef
- Verso M, Agnelli G, Bertoglio S, Di Somma FC, Paoletti F, Ageno W, Bazzan M, Parise P, Quintavalla R, Naglieri E, Santoro A, Imberti D, Soraru M, Mosca S: Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 2005,23(18):4057–4062. CrossRef
- Young AM, Billingham LJ, Begum G, Kerr DJ, Hughes AI, Rea DW, Shepherd S, Stanley A, Sweeney A, Wilde J, Wheatley K: Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial. Lancet 2009,373(9663):567–574. CrossRef
- Krotenberg R, Adler U, Pomeranz B, Miller JD, Russell MW: Dalteparin vs. enoxaparin as prophylaxis for deep-vein thrombosis after total hip or knee arthroplasty: a retrospective analysis. Am J Phys Med Rehabil 2001,80(12):889–895. CrossRef
- Wiener RS, Schwartz LM, Woloshin S: Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011,171(9):831–837. CrossRef
- Tapson VF: Acute pulmonary embolism: comment on "time trends in pulmonary embolism in the United States". Arch Intern Med 2011,171(9):837–839. CrossRef
- Browne AM, Cronin CG, English C, NiMhuircheartaigh J, Murphy JM, Bruzzi JF: Unsuspected pulmonary emboli in oncology patients undergoing routine computed tomography imaging. J Thorac Oncol 2010,5(6):798–803. CrossRef
- Tagalakis V, Kahn SR: Determining the test characteristics of claims-based diagnostic codes for the diagnosis of venous thromboembolism in a medical service claims database. Pharmacoepidemiology Drug Saf 2011,20(3):304–307. CrossRef
- Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH: Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012, 141:e195S-e226S. CrossRef
- Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM: Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012, 141:e227S-e277S. CrossRef
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/12/92/prepub
- Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: a quasi-experimental study
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
BMC Medical Informatics and Decision Making
- Online Date
- August 2012
- Online ISSN
- BioMed Central
- Additional Links
- Electronic medical record
- Electronic health record
- Health information technology
- Clinical decision support
- Venous thrombosis
- Deep venous thrombosis
- Quasi-experimental study
- Author Affiliations
- 1. Center for Evidence-based Practice, University of Pennsylvania, Suite 50 Mezzanine, 3535 Market Street, Philadelphia, PA, USA
- 2. Department of Medicine, University of Pennsylvania, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA, USA
- 3. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 3535 Market Street, Mezzanine Suite 50, Philadelphia, PA, USA
- 4. Leonard Davis Institute of Health Economics, University of Pennsylvania, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA, USA