venous thromboembolism

Transcription

1 Venous thromboembolism reduction initiative: A multifaceted collaborative effort to protect Intermountain Healthcare patients from hospitalassociated venous thromboembolism (HA-VTE) 14 th Annual Research Summit April 6, 2017 Scott C. Woller, MD Co-Director Thrombosis Program Intermountain Medical Center Professor of Medicine University of Utah School of Medicine

2 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)

3 Objectives The importance of thromboprophylaxis among hospitalized medical patients Outcomes of VTE reduction initiative (VRI) Discussion

4 Risk of Thrombosis Hospitalization for acute medical illness increases the risk of VTE 8-fold 1 2/3 of VTE events are attributable to hospitalization % of fatal PE occur in nonsurgical patients 2 Chemoprophylaxis decreases VTE among patients at risk 3 Risk factors for VTE are well described 1. Heit JA Arch Int Med 2000; Goldhaber SZ CHEST 2000; 118(6) 3. Kahn et al. CHEST 2012; 141(2)(Suppl):e195S e226s

5 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)

6 Background: Intermountain VTE High Risk Alert VTE HIGH RISK for IMC 02/21/ :00 SMITH, JOHN MMI: 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

7 Woller SC etal. The Am J Med (2016) 129, 1124.e e26

8 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

9 Venous thromboembolism Reduction initiative OBJECTIVES Secondary objectives: VTE Major bleeding Heparin-induced thrombocytopenia (HIT) Alert fatigue Physician satisfaction

10 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

11 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

12 Physician interface with personalized VTE RAM John Doe x John Doe REJECT the VTE Risk Alert and OR select the rationale to turn off the text page alert for 5 days providing credit for appropriate prophylaxis 12

13 Individual Physician Feedback

14 Physician-tailored continuing medical education 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.

15 Physician-tailored continuing medical education

16 System Rate of VTE Prophylaxis

17 Figure 1 Low Risk 63,717 days 20,186 patient encounters High Risk 44,794 days 15,195 patient encounters 481 patient encounters overlap risk groups 18,923 days 5,472 patient encounters ,485 days 3,748 patient encounters ,055 days 5,414 patient encounters ,254 days 6,069 patient encounters ,558 days 1,421 patient encounters ,788 days 2,303 patient encounters ,577 days 1,767 patient encounters 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 Woller SC etal. The Am J Med (2016) 129, 1124.e e26

18 Woller SC etal. The Am J Med (2016) 129, 1124.e e26

19 RESULTS Woller SC etal. The Am J Med (2016) 129, 1124.e e26

20 Percentage of appropriate chemoprophylaxis Primary Objective The rate of appropriate chemoprophylaxis increased: 66.1% control period 81.0% intervention period 88.1% subsequent year Rate of appropriate chemoprophylaxis among high risk patients P <.001 for each comparison APR JUL OCT JAN APR JUL OCT JAN APR JUL OCT JAN Each dot represents the average monthly rate of appropriate chemoprophylaxis Woller SC etal. The Am J Med (2016) 129, 1124.e e26

21 Percentage of Appropriate Chemoprophylaxis Overall Percentage of Appropriate Chemoprophylaxis by Hospitalist Hospitalist Each bar represents the annual rate of appropriate chemoprophylaxis ordered by each hospitalist (A-X) for the years 2010, 2011, and Woller SC etal. The Am J Med (2016) 129, 1124.e e26

22 Secondary Objectives Rate of venous thromboembolism, mortality, major bleeding, and heparin induced thrombocytopenia among high-risk patients stratified by year (95% Confidence Interval) p-value 90 day VTE % 9.3 ( ) 9.7 ( ) 6.7 ( ) day VTE % 7.3% ( ) 7.9 ( ) 4.9 ( ) day all-cause mortality % 13.0 ( ) 12.7 ( ) 12.5 ( ) 0.96 In-hospital mortality % 2.4 ( ) 2.1 ( ) 1.6 ( ) 0.43 Thromboprophylaxis Yes: in-hospital HIT* % 0.1 ( ) 0.2 ( ) 0.1 ( ) 0.96 Yes: Major bleeding* % 0.8 ( ) 0.8 ( ) 1.1 ( ) 0.96 No: Major bleeding* % 1.8 ( ) 2.0 ( ) 2.1 ( ) 0.96 Woller SC etal. The Am J Med (2016) 129, 1124.e e26

23 Event Rate Secondary Objectives 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. Quarterly rates of behavioral change among hospitalists during the intervention year Q1 Q2 Q3 Q Woller SC etal. The Am J Med (2016) 129, 1124.e e26

24 CONCLUSIONS 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 Woller SC etal. The Am J Med (2016) 129, 1124.e e26

25 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

26 NEXT STEPS

27 TRANSLATING CLINICAL DATA INTO PRACTICE Outcomes/CER/ Clinical Trials Prediction Models Improved Health Refining the Evidence Facilitating physician adoption Delivering the Evidence

28 THANK YOU Intermountain Research and Medical Foundation Twine Clinical LLC Intermountain Healthcare Hospitalist Group Dr. Scott M. Stevens, MD Dr. C. Greg Elliott, MD Dr. R. Scott Evans, Ph.D. Dr. John Christensen, MD Matthew H. Wayne Daniel G. Wray Jim Lloyd Valerie Aston Emily Wilson

29 QUESTIONS