Skip Navigation
Text Size: A A A

Panel 6: STRATEGIES TO IMPROVE THE USE OF VTE PROPHYLAXIS

Surgeon General's Workshop on Deep Vein Thrombosis

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12

Return to Menu


 SLIDE 1: STRATEGIES TO IMPROVE THE USE OF VTE PROPHYLAXIS

Samuel Z. Goldhaber, MD
Cardiovascular Division
Brigham and Women’s Hospital
Professor of Medicine
Harvard Medical School
May 9, 2006

 

Return to Top

 SLIDE 2: CHANGING MD BEHAVIOR

  • Guidelines alone do not suffice
  • Strategies for change
    • Surgeon General’s DVT Workshop
    • Physician champions
    • Registries
    • Coalitions (Coalition to Prevent DVT)
    • Litigation
    • Electronic alerts

Return to Top

 SLIDE 3: QUALITY IMPROVEMENT INITIATIVE TO IMPROVE CLINICAL PRACTICE

  • Randomized controlled trial to issue or withhold electronic alerts to MDs whose high-risk patients were not receiving DVT prophylaxis

Return to Top

 SLIDE 4: COMPUTER PROGRAM

  • We developed a computer program linked to the patient database that screened the system daily to identify high-risk patients.
  • We included consecutive high-risk patients on medical and surgical services who were not receiving DVT prophylaxis.

Return to Top

 SLIDE 5: DEFINITION: “HIGH RISK”

VTE risk score > points:

  • Cancer 3 (ICD codes)
  • Prior VTE 3 (ICD codes)
  • Hypercoagulability 3 (Leiden, ACLA)
  • Major surgery 2 (> 60 minutes)
  • Bed rest 1 (“bed rest” order)
  • Advanced age 1 (> 70 years)
  • Obesity 1 (BMI > 29 kg/m2)
  • HRT/OC 1 (order entry)

Return to Top

 SLIDE 6: RANDOMIZATION
 

VTE risk score > 4 No prophylaxis N = 2506

with arrows pointing to:

  • INTERVENTION Single alert n = 1255
  • CONTROL No alert n = 1251

Return to Top

 SLIDE 7: ALERT MESSAGE

Screen shot of an alert indicating patient is at high risk for deep vein thrombosis, according to the BWH guidelines.

Return to Top

 SLIDE 8: BASELINE CHARACTERISTICS
 

  • Median age: 62.5 years
  • Medical services: 83%
  • Surgical services: 17%
  • Comorbidities
    • Cancer: 80%
    • Hypertension: 34%
    • Infection: 30%
    • Prior VTE: 20%

Return to Top

 SLIDE 9: ORDERS: DVT PROPHYLAXIS

 
Intervention
n = 1255
Control
n = 1251
 
P value
Overall
421 (33.5)
182 (14.5)
< 0.001
Mechanical
125 (10.0)
19 (1.5)
< 0.001
GCS
52 (4.1)
7 (0.6)
< 0.001
IPC
73 (5.8)
12 (1.0)
< 0.001
Pharmacologic
296 (23.6)
163 (13.0)
< 0.001
Heparin
213 (17.0)
81 (6.5)
< 0.001
Warfarin
28 (2.2)
41 (3.3)
0.11
Enoxaparin
55 (4.4)
41 (3.3)
0.18
(Kucher N, et al. NEJM 2005;352:969-977)

Return to Top

 SLIDE 10: PRIMARY END POINT: 90 DAYS

 Intervention
(n = 1255)
 		Control
(n = 1251)		Hazard ratio
(95% CI)		P
Total VTE61 (4.9)103 (8.2)0.59 (0.43–0.81)0.001
Acute PE14 (1.1)35 (2.8)0.40 (0.21–0.74)0.004
Prox. DVT10 (0.8)23 (1.8)0.47 (0.20–1.09)0.08
Distal DVT5 (0.4)12 (1.0)
0.42 (0.15–1.18)		0.10
UE DVT32 (2.5)33 (2.6)0.97 (0.60–1.58)0.90

Return to Top

 SLIDE 11: PRIMARY END POINT
 

Line chart showing intervention and control primary end points. The primary end point of symptomatic and imaging-confirmed DVT or pulmonary embolism occurred in 61 intervention-group and 103 control-group patients. At 90 days, the intervention strategy reduced the risk of DVT or pulmonary embolism by 41%

Return to Top

 SLIDE 12: RISK SCORE AND PROPHYLAXIS

 
Present Cohort n(%)
Historical Intervention n(%)
p
Patients at risk of VTE with alert sent411 (7%)1255 (18%)p <0.001
Services
Medical330 (80)1038 (82)p=0.30
Surgical81 (19)217 (17)p=0.30
Cumulative Risk Score
4266 (64)792 (63)p=0.60
5101 (24)327 (26)p=0.60
637 (9)110 (9)p=0.96
77 (1)22 (2)p=0.88
80 (0)4 (0.3)p=0.57
Prophylaxis Prescribed166 (40%)421 (34%)p=0.01

Return to Top

 SLIDE 13: VTE PROPHYLAXIS: THE FUTURE

  1. Can a 3-screen alert improve physician response (34% in RCT and 40% in cohort)?
  2. Should we use an “opt in” vs. “opt out” strategy for alerts?
  3. Can human alerts function as well or better than electronic alerts?

Return to Top