Electronic alerts, comparative practitioner metrics, and education improve thromboprophylaxis and reduce venous thrombosis in community hospitals

Abstract

Background: Venous thromboembolism prophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We previously reported that a multifaceted intervention was associated with a sustained increase in appropriate thromboprophylaxis and reduced symptomatic venous thromboembolism among medical patients hospitalized in two urban teaching hospitals. The effectiveness of this intervention in community hospitals is unknown.

Methods: We performed a prospective multicenter cohort study in three community hospitals. All medical patients admitted from February 1, 2011 to January 31, 2014 were eligible. Consecutive eligible patients were enrolled into the 12-month "control," 12-month "intervention," or 12-month "maintenance" group. We provided electronic alerts, physician performance feedback, and targeted medical education for the intervention group. Only the alert component of the intervention continued in the maintenance group. The primary outcome was the rate of appropriate thromboprophylaxis among patients at high risk for venous thromboembolism defined as the prescription of guideline recommended chemoprophylaxis, or identification of a chemoprophylaxis contraindication. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue.

Results: Appropriate thromboprophylaxis when compared to the control group rate of 67% was higher for the intervention group (85%) and for the maintenance group (77%; P < .001 for each comparison). A reduction of 90-day symptomatic venous thromboembolism accompanied the intervention (control 4.5%, intervention 3.4%, maintenance 3.0%, P = .04).

Conclusions: This multifaceted intervention was associated with an overall increase in appropriate thromboprophylaxis of medical patients compared with the control period. Hospital-associated venous thrombosis rates decreased.

Keywords: prevention; quality improvement; thromboprophylaxis medical patient; venous thromboembolism.

Figure 1

The grey dashed line represents the rate of appropriate thromboprophylaxis of all hospitals. The line with an embedded black dot, blue square, and green triangle represent the rate of appropriate thromboprophylaxis hospitals 1, 2, and 3, respectively

Figure 2

Each bar represents the annual rate of appropriate thromboprophylaxis ordered by each hospitalist (A‐T) for the control (white), intervention (blue), and maintenance (grey) years

Figure 3

The grey dashed line represents the rate of 90‐day VTE of all hospitals. The line with an embedded black dot, blue square, and green triangle represent the rate of rate of 90‐day VTE of hospitals 1, 2, and 3, respectively. VTE, venous thromboembolism