Surgeon General's Workshop on Deep Vein Thrombosis: Workshop Presentations

Surgeon General's Workshop on Deep Vein Thrombosis

Panel 6: STRATEGIES TO IMPROVE THE USE OF VTE PROPHYLAXIS

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

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

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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

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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

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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.

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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)

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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

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SLIDE 7: ALERT MESSAGE

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

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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%

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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)

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SLIDE 10: PRIMARY END POINT: 90 DAYS

	Intervention (n = 1255)	Control (n = 1251)	Hazard ratio (95% CI)	P
Total VTE	61 (4.9)	103 (8.2)	0.59 (0.43–0.81)	0.001
Acute PE	14 (1.1)	35 (2.8)	0.40 (0.21–0.74)	0.004
Prox. DVT	10 (0.8)	23 (1.8)	0.47 (0.20–1.09)	0.08
Distal DVT	5 (0.4)	12 (1.0)	0.42 (0.15–1.18)	0.10
UE DVT	32 (2.5)	33 (2.6)	0.97 (0.60–1.58)	0.90

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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%

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SLIDE 12: RISK SCORE AND PROPHYLAXIS

	Present Cohort n(%)	Historical Intervention n(%)	p
Patients at risk of VTE with alert sent	411 (7%)	1255 (18%)	p <0.001
Services
Medical	330 (80)	1038 (82)	p=0.30
Surgical	81 (19)	217 (17)	p=0.30
Cumulative Risk Score
4	266 (64)	792 (63)	p=0.60
5	101 (24)	327 (26)	p=0.60
6	37 (9)	110 (9)	p=0.96
7	7 (1)	22 (2)	p=0.88
8	0 (0)	4 (0.3)	p=0.57
Prophylaxis Prescribed	166 (40%)	421 (34%)	p=0.01

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SLIDE 13: VTE PROPHYLAXIS: THE FUTURE

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

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