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Venous thromboembolism reduction initiative:
Scott C. Woller, MD Co-Director Thrombosis Program
Intermountain Medical CenterProfessor of Medicine
University of Utah School of MedicineApril 6, 2017
A multifaceted collaborative effort to protect Intermountain Healthcare patients from hospital-
associated venous thromboembolism (HA-VTE)
14th Annual Research Summit
Disclosures
Investigator initiated grant recipient: Bristol-Myers-Squibb (paid to Intermountain Healthcare)
Grant support from Twine Clinical LLC (paid to Intermountain Healthcare)
Grant support from the Intermountain Research and Medical Foundation
Panelist American College of Chest Physicians (ACCP) Clinical Practice Guideline: Antithrombotic therapy for venous thromboembolic disease (AT10)
Objectives
The importance of thromboprophylaxis among hospitalized medical patients
Outcomes of VTE reduction initiative (VRI)
Discussion
Risk of Thrombosis
Hospitalization for acute medical illness increases the risk of VTE 8-fold1
• 2/3 of VTE events are attributable to hospitalization2
• 70-80% of fatal PE occur in nonsurgical patients2
Chemoprophylaxis decreases VTE among patients at risk3
Risk factors for VTE are well described
1. Heit JA Arch Int Med 2000;162. 2. Goldhaber SZ CHEST 2000; 118(6)3. Kahn et al. CHEST 2012; 141(2)(Suppl):e195S–e226S
Thromboprophylaxis recommendations
2.3. “For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with LMWH, LDUH B.I.D., LDUH T.I.D., or fondaparinux (1B)”
2.4. “For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (1B)”
VTE HIGH RISK for IMC 02/21/2010.07:00
SMITH, JOHN MMI: 1234567 Admit: 02/13/2010 RM: T345
Age: 89 CA: 3 Prior VTE: 3 Hyper: 0 Surg: 0 Bedrest: 0 Obese: 0
HRT/OCP: 0 VTE Risk Score: 7
Current Prophylaxis: NONE
Background: Intermountain VTE High Risk Alert
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Venous thromboembolism Reduction initiative
OBJECTIVES
Primary objective:Report the rate of appropriate chemoprophylaxis among hospitalized medical patients at high risk for VTE before and after the implementation of a multifaceted intervention including:• (a) targeted electronic alerts for high-risk patients
• (b) comparative practitioner metrics
• (c) practitioner-specific continuing medical education
Venous thromboembolism Reduction initiative
OBJECTIVES
Secondary objectives:• VTE
• Major bleeding
• Heparin-induced thrombocytopenia (HIT)
• Alert fatigue
• Physician satisfaction
Venous thromboembolism Reduction initiative
All hospitalists provided signed informed consent
Participation in the VRI and completion of all educational modules served as part of the 2011 hospitalist group incentive initiative
Hospitalist perceptions of the VRI were assessed in a standardized format at the time of initiation and at the end of the intervention year
IRB approval was granted by Intermountain Healthcare
Physician interface with personalized VTE RAM
Every morning at 0905 hours (rounding) a “just in time” text page was sent the hospitalist’ pager or cell phone if the patient met HA-VTE Risk criteria
Actionable EMR alert sent in conjunction with the text page
Physician interface with personalized VTE RAM
12
John Doe
John Doe
OR“REJECT” the VTE Risk Alert and select the rationale to turn off the text page alert for 5 days providing “credit” for appropriate prophylaxis
x
Individual Physician Feedback
The recommended educational activity is based on physician
performance data.
In this case, 12% of the instances of suboptimal prophylaxis (i.e. alerts
generated) were in cancer patients.
The recommendation for the track focused on thrombosis in cancer.
Physician-tailored continuing medical education
Physician-tailored continuing medical education
System Rate of VTE Prophylaxis
Summary of total patient days and patient encounters: overall, by risk group, and by year.
Patient encounter: a hospitalization
Patient day: a day the patient was in the hospital
Figure 1
Low Risk
2011
15,055 days
5,414 patient
encounters
2010
12,485 days
3,748 patient
encounters
2012
17,254 days
6,069 patient
encounters
High Risk63,717 days
20,186 patient encounters
44,794 days
15,195 patient encounters18,923 days
5,472 patient encounters481 patient encounters
overlap risk groups
2010
5,558 days
1,421 patient
encounters
2011
7,788 days
2,303 patient
encounters
2012
5,577 days
1,767 patient
encounters
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
RESULTS
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Primary Objective
The rate of appropriate chemoprophylaxis increased:
66.1% control period
81.0% intervention period
88.1% subsequent year
P <.001 for each comparison
Each dot represents the average monthly rate of appropriate chemoprophylaxis
Rate of appropriate chemoprophylaxis
among high risk patients
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
2010 2011 2012
Per
cen
tag
e o
f ap
pro
pri
ate
chem
op
rop
hyl
axis
APR JUL OCT JAN APR JUL OCT JAN APR JUL OCT JAN
Each bar represents the annual rate of appropriate chemoprophylaxis ordered by each hospitalist (A-X) for the years 2010, 2011, and 2012.
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Hospitalist
Pe
rce
nta
ge o
f A
pp
rop
riat
e C
he
mo
pro
ph
ylax
is
Overall Percentage of Appropriate Chemoprophylaxis by Hospitalist
Secondary Objectives
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Rate of venous thromboembolism, mortality, major bleeding, and heparin
induced thrombocytopenia among high-risk patients stratified by year(95% Confidence Interval) 2010 2011 2012 p-value
90 day VTE % 9.3 (7.8-10.9) 9.7 (8.5-11.0) 6.7 (5.6-8.0) 0.00930 day VTE % 7.3% (6.0-8.8) 7.9 (6.8-9.1) 4.9 (3.9-6.0) 0.00390 day all-cause mortality % 13.0 (11.2-14.9) 12.7 (11.3-14.1) 12.5 (10.9-14.1) 0.96In-hospital mortality % 2.4 (1.7-3.4) 2.1 (1.5-2.7) 1.6 (1.0-2.3) 0.43Thromboprophylaxis
Yes: in-hospital HIT* % 0.1 (0.0-0.5) 0.2 (0.0-0.5) 0.1 (0.0-0.4) 0.96Yes: Major bleeding* % 0.8 (0.4-1.6) 0.8 (0.5-1.3) 1.1 (0.6-1.7) 0.96No: Major bleeding* % 1.8 (0.6-4.1) 2.0 (0.9-3.9) 2.1 (0.8-4.6) 0.96
Secondary Objectives
Quarterly rates of behavioral change among
hospitalists during the intervention year
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
Eve
nt
Rat
eQ1 Q2 Q3 Q4
2011
Drop in alerts yet the rate of appropriate chemoprophylaxis increased.
Hospitalist response to the alerts increased over time, which refutes concern surrounding alert fatigue.
Suggestive that over time the hospitalists’ perceived increased value associated with the alerts.
CONCLUSIONS
Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26
The VRI was associated with a significant increase in appropriate VTE prophylaxis
We observed a reduction in symptomatic HA-VTE
The VRI was well received by clinicians
SLIDE HEADING, CALIBRI 36 PT., ALL CAPS
Slide subhead, Calibri Body, 28 pt.• Key point number 1
• Key point number 2
• Key point number 3
o Supporting point number 3.1
o Supporting point number 3.2
https://www.cdc.gov/ncbddd/dvt/ha-vte-challenge.html
NEXT STEPS
http://www.clipartkid.com/foot-steps-cliparts/
TRANSLATING CLINICAL DATA INTO PRACTICEOutcomes/CER/
Clinical TrialsPrediction
ModelsImproved
Health
Refining the Evidence
Delivering the Evidence
Facilitating physician adoption
THANK YOUIntermountain Research and Medical Foundation
Twine Clinical LLC
Intermountain Healthcare Hospitalist Group
Dr. Scott M. Stevens, MDDr. C. Greg Elliott, MDDr. R. Scott Evans, Ph.D.Dr. John Christensen, MDMatthew H. WayneDaniel G. WrayJim LloydValerie AstonEmily Wilson
QUESTIONS
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