Patient Education Program for Venous Thromboembolism Prevention in Hospitalized Patients

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1 CLINICAL RESEARCH STUDY Patient Education Program for Venous Thromboembolism Prevention in Hospitalized Patients Gregory Piazza, MD, MS, a Thanh Nha Nguyen, PharmD, b Ruth Morrison, RN, b Deborah Cios, PharmD, c Benjamin Hohlfelder, b John Fanikos, RPh, MBA, c Marilyn D. Paterno, MBI, d Samuel Z. Goldhaber, MD a a Cardiovascular Division, Department of Medicine, Brigham and Women s Hospital, Harvard Medical School, Boston, Mass; b Venous Thromboembolism Research Group and c Department of Pharmacy, Brigham and Women s Hospital, Boston, Mass; d Clinical Informatics Research and Development, Partners HealthCare System, Division of General Medicine, Brigham and Women s Hospital, Harvard Medical School, Boston, Mass. ABSTRACT PURPOSE: Up to 15% of clinician-ordered doses of injectable pharmacological prophylaxis to prevent venous thromboembolism are not administered. Patient refusal accounts for nearly 50% of these omitted doses. We conducted a prospective cohort study to determine whether a patient education program would improve medication adherence to clinician-ordered injectable prophylactic anticoagulation. METHODS: We identified 528 hospitalized patients ordered to receive injectable pharmacological venous thromboembolism prophylaxis. We evaluated the impact of pharmacist-led patient education sessions on medication adherence (defined as the ratio of doses administered to doses scheduled) compared with our historical cohort. RESULTS: Individualized patient education sessions were conducted within 24 hours of the initial order for prophylactic anticoagulation in 99% of patients. Adherence to clinician-ordered pharmacological venous thromboembolism prophylaxis was higher after the patient education program than in our historical cohort (94.4% vs 89.9%, P.0001). The proportion of patients receiving 100% of scheduled doses of injectable was higher after our novel patient education program than in our historical cohort (73.7% vs 62.4%, P.001). Patient refusal as a reason for omitted doses was less frequent after the patient education program (29.3% vs 43.7%, P.001). CONCLUSION: Pharmacist-led individualized patient education sessions were associated with higher medication adherence to clinician-ordered injectable and a reduction in patient refusal as a reason for omitted doses. A randomized controlled trial to evaluate the impact of a patient education program on medication adherence to pharmacological venous thromboembolism prophylaxis is warranted Elsevier Inc. All rights reserved. The American Journal of Medicine (2012) 125, KEYWORDS: Anticoagulation; Medication adherence; Patient education; Prevention; Venous thromboembolism The 2008 US Surgeon General s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism 1 estimates that 100,000 to 180,000 deaths occur annually from pulmonary embolism in the US alone and identifies venous Funding: This study was funded, in part, by an unrestricted clinical research grant from sanofi-aventis. Dr Goldhaber (Principal Investigator), Thanh Nha Nguyen (research pharmacist), and Ruth Morrison (research nurse) were partially compensated with these funds. Dr Piazza is supported by a Research Career Development Award (K12 HL083786) from the National Heart, Lung, and Blood Institute (NHLBI). Conflict of Interest: Dr Goldhaber receives clinical research grant support from sanofi-aventis. None of the other authors have any conflicts of interest to disclose. thromboembolism as the most preventable cause of inhospital death. In our analysis of the 2003 US Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample database, 196,134 venous thromboembolism-related events, including symptomatic deep vein thrombosis, symptomatic pulmonary embolism, and venous thromboem- Authorship: All of the authors had access to the data and participated in the writing of the manuscript. Requests for reprints should be addressed to Gregory Piazza, MD, Cardiovascular Division, Brigham and Women s Hospital, 75 Francis St., Boston, MA address: gpiazza@partners.org /$ -see front matter 2012 Elsevier Inc. All rights reserved. doi: /j.amjmed

2 Piazza et al Patient Education for Thromboprophylaxis 259 bolism-related deaths, were calculated to have occurred among acutely ill hospitalized Medical Service patients, afflicting 2 of every 100 of these patients. 2 If universal thromboprophylaxis had been utilized, 60% of these venous thromboembolismrelated events could be prevented, 2 and the number of patients with long-term complications, including venous thromboembolismrelated death, recurrent venous thromboembolism, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension, could be reduced by 60%. 3 Despite published expert guidelines for prevention of venous CLINICAL SIGNIFICANCE thromboembolism, 4,5 underutilization of thromboprophylaxis in hospitalized medical patients remains problematic in the US, 6 Canada, 7 and worldwide. 8 Quality improvement initiatives utilizing computerized decision support 9,10 as well as nonelectronic strategies 11,12 improve thromboprophylaxis prescription among hospitalized medical patients. However, while strategies for improving thromboprophylaxis prescription rates are critical to venous thromboembolism prevention, they do not guarantee that patients will receive adequate pharmacological or mechanical prophylactic measures. To assess patterns of adherence to clinician-ordered thromboprophylaxis, we identified and followed 250 consecutive patients who were ordered to receive pharmacological venous thromboembolism prophylaxis. 13 Pharmacological prophylaxis adherence, defined as the ratio of doses administered to doses ordered, was greater with enoxaparin once daily (94.9%) compared with unfractionated heparin twice daily (86.8%) or 3 times daily (87.8%) (P.001). We were surprised to learn that patient refusal was the most common reason for omitted clinician-ordered pharmacological venous thromboembolism prophylaxis doses. Patient refusal accounted for 44.5% of unfractionated heparin orders and 39.4% of enoxaparin orders that were not executed. We hypothesized that patients were not adequately educated about the rationale for prescribing these prophylactic anticoagulants. Based on this hypothesis and our initial findings, we designed a prospective cohort study to assess the impact of an in-hospital pharmacist-led individualized patient education program to improve medication adherence to clinician-ordered injectable prophylactic anticoagulation. METHODS Patient Population Brigham and Women s Hospital is a 793-bed acute tertiary care facility providing medical and surgical care for patients with general medical, cardiothoracic, orthopedic, Short-duration pharmacist-led patient education sessions were associated with a higher medication adherence to injectable pharmacological thromboprophylaxis. Patient refusal as a reason for omitted doses of thromboprophylaxis was less frequent after the patient education intervention. The patient education program was feasible, with 99% of sessions completed within 24 hours of the initial order for thromboprophylaxis. oncologic, neurologic, obstetric and gynecologic, neonatal, urologic, and gastrointestinal conditions. Brigham and Women s Hospital utilizes a Medical Informatics System that integrates an online medical record, computerized provider order entry, and an electronic medication administration record. Identification of Study Subjects Using our event-based rules engine to detect orders written in our computerized provider order entry system, we generated a daily list of patients who were admitted to Medical and Surgical Service units and who were ordered for injectable pharmacological venous thromboembolism prophylaxis. The list was designed to capture orders for injectable thromboprophylaxis agents including dalteparin, unfractionated heparin, and fondaparinux. A group consisting of several research pharmacists and a nurse reviewed the list on a daily basis, Monday through Friday. The list was not generated on weekend days, and therefore, patients were not enrolled on Saturday and Sunday. Patients who were at least 18 years old, admitted to the Medical or Surgical Service, and ordered for injectable pharmacological venous thromboembolism prophylaxis were eligible for inclusion. Patients who did not speak and understand English or who were delirious, cognitively impaired, unresponsive, or otherwise unable to participate in the patient education session were excluded. Verbal informed consent was obtained from all study patients. Of the 580 patients who were eligible for enrollment into the study, 52 patients were excluded because of refusal to provide informed consent, being away for testing or a procedure, or being asleep. Each of the remaining 528 patients participated in the patient education session. Patient Education Intervention A one-on-one patient education session was conducted at the bedside by a research pharmacist (PharmD) within 24 hours of the first appearance of an order for injectable in the computerized provider order entry program. The patient education intervention required approximately 45 minutes to identify and prepare for the session and 15 minutes to perform the teaching exercise. Using a scripted patient education tool (Appendix), the research pharmacist provided information about the risk of venous thromboembolism in hospitalized patients, the rationale for pharmacological venous thromboembolism prophylaxis, and the importance of adherence to the thromboprophylactic regimen. Following the scripted portion of the session, each patient was given

3 260 The American Journal of Medicine, Vol 125, No 3, March 2012 the opportunity to ask questions or voice concerns about venous thromboembolism risk and its prevention. The study was approved by the Partners Human Research Committee. Follow-up After the patient education session, patients were followed for the duration of the hospitalization until 90 days after the patient education session. The electronic medication administration record was used to document the type and frequency of injectable pharmacological venous thromboembolism prophylaxis, the total number of doses scheduled to be given, the total number of doses administered, and the reasons for any missed doses. Medication adherence was defined as the ratio of the total number of doses administered to the total number of doses scheduled. Patient demographic and baseline clinical characteristics including age, sex, race, weight and height, admitting diagnosis, and length of stay were recorded. A venous thromboembolism risk score was calculated for each patient using a previously validated risk-scoring system that assigned 3 points each for previous venous thromboembolism, active cancer, and thrombophilia, 2 points for major surgery or trauma within the prior 30 days, and 1 point each for obesity, active use of oral contraceptive or hormonal replacement therapy, immobility or bed rest, and age 70 years or older. 9 Obesity was defined as a body mass index of 29.9 kg/m 2. Clinical events, including symptomatic venous thromboembolism, all-cause mortality, and major bleeding within 90 days of the patient education session, were identified using data from the index admission, subsequent hospitalizations, and office visits, including discharge summaries, health care providers notes, laboratory test results, vascular laboratory reports, nuclear medicine reports, and radiology reports. If patient vital status at 90 days could not be determined, the Social Security Death Index was used to identify patients who died during the 90-day follow-up period. Ninety-day follow-up was completed for 100% of study patients. Data Collection The primary study end point was medication adherence to clinician-ordered injectable pharmacological venous thromboembolism prophylaxis. Secondary end points included symptomatic deep vein thrombosis or pulmonary embolism, all-cause mortality, major bleeding events, and non-bleeding-related adverse drug reactions resulting in discontinuation of thromboprophylaxis within 90 days of the patient education session. Cause of death was categorized as due to cardiovascular disease, cancer, or other disease process. We defined major bleeding as intracranial, intraocular, retroperitoneal, or pericardial bleeding, or bleeding that required surgical intervention or clinically overt bleeding that resulted in a hemoglobin decrease of 3 g/dl. 14 Deep vein thrombosis was diagnosed if there was loss of compressibility on venous ultrasonography 15 or evidence of a filling defect on invasive contrast venography. Pulmonary embolism was diagnosed on the basis of findings on contrastenhanced chest computed tomography, 16 ventilation-perfusion lung scanning, or invasive pulmonary angiography. Events suspected clinically to be venous thromboembolism-related were not counted unless objective diagnostic imaging evidence was obtained. Statistical Methods Based on our prior study of medication adherence for clinician-ordered injectable pharmacological venous thromboembolism prophylaxis, we estimated that our patient education program would increase medication adherence to 94% from an overall baseline of 89% in our historical cohort. Accordingly, we calculated a sample size of 527 patients for this study (assuming 80% power to detect a difference and a 2-sided alpha of 0.05). We aimed for a trial enrollment of 580 patients to allow for a cushion of 53 patients who refused to provide informed consent, were unavailable for the patient education session, or withdrew from the study. Descriptive statistics including baseline characteristics, variables related to injectable pharmacological venous thromboembolism prophylaxis, and those pertaining to outcomes were stratified as continuous or binary. Continuous variables were assessed for normality of distribution, and nonparametric data were presented as medians with interquartile ranges. Binary variables were presented as numbers and proportions. Comparative statistics for categorical variables, including medication adherence, proportion of patients receiving 100% of scheduled doses of injectable pharmacological venous thromboembolism prophylaxis, and patient refusal as a reason for omitted doses, were calculated using the chi-squared test. Comparative statistics were calculated for medication adherence between different regimens and for medication adherence, proportion of patients receiving 100% of scheduled doses of injectable pharmacological venous thromboembolism prophylaxis, and patient refusal as a reason for omitted doses between the patient education and historical cohorts. All reported P-values were 2-sided, and a P-value of.05 was considered statistically significant. All statistical analyses were performed using STATA version 9.2 (StataCorp LP, College Station, Tex). RESULTS Baseline Demographics and Clinical Characteristics Patient education sessions were conducted for all 528 hospitalized patients enrolled in the study. Subjects enrolled in the patient education program had a median age of 58 years and a median venous thromboembolism risk score of 3 (Table 1). The median length of stay was 4 days.

4 Piazza et al Patient Education for Thromboprophylaxis 261 Pharmacological Venous Thromboembolism Prophylaxis Subcutaneously administered unfractionated heparin (54.9%) was the most frequently prescribed form of pharmacological venous thromboembolism prophylaxis followed by subcutaneously administered dalteparin (44.7%) (Table 2). One patient initially ordered for injectable pharmacological venous thromboembolism prophylaxis was switched to oral warfarin therapy after the patient education session. The most common frequency of thromboprophylaxis was 3 times daily (54.2%) followed by once daily (45.3%), corresponding to the use of unfractionated heparin and dalteparin, respectively. The median duration of pharmacological venous thromboembolism prophylaxis prescription was 2 days. Table 1 Baseline Clinical Characteristics (n 528) Median age (interquartile range), years 58 (46-70) Age 70 years, 134 (25.4) Male, 221 (41.9) Race, White 394 (74.6) Black 91 (17.3) Hispanic 31 (5.9) Asian 10 (1.9) Native Hawaiian 1 (0.2) American Indian/Alaskan Native 1 (0.2) Median body mass index (interquartile range), 29 ( ) kg/m 2 Prior venous thromboembolism, 30 (5.7) Thrombophilia, 4 (0.8) History of cancer, 113 (21.4) Surgery or trauma within 30 days, 250 (47.4) Bed rest or immobilization within 30 days, 16 (3) Oral contraceptive or hormone replacement 14 (2.7) therapy, Obesity, 236 (44.7) Venous thromboembolism risk score, 0 63 (12.1) (21.5) 2 75 (14.4) (28.2) 4 58 (11.1) 5 28 (5.4) 6 24 (4.6) 7 12 (2.3) 8 3 (0.6) Median venous thromboembolism risk score 3 (1-3) (interquartile range) Median length of stay (interquartile range), 4 (3-6) days Table 2 Characteristics of Pharmacological Venous Thromboembolism Prophylaxis Thromboprophylaxis agent, Subcutaneous unfractionated heparin 290 (54.9) Subcutaneous dalteparin 236 (44.7) Subcutaneous fondaparinux 1 (0.2) Other 1 (0.2) Frequency of thromboprophylaxis, Daily 239 (45.3) Twice daily 3 (0.6) Three times daily 286 (54.2) Thromboprophylaxis continued at hospital 38 (7.2) discharge, Median duration of prophylaxis (interquartile 2 (1-4) range), days Patient Education Patient education sessions were provided within 24 hours of the initial order for pharmacological venous thromboembolism prophylaxis in 99% of patients (Table 3). Only 3% of patients asked questions about their risk for venous thromboembolism or the use of injectable prophylactic anticoagulation for venous thromboembolism prevention. The most frequently asked question (33.3%) pertained to the patient s risk for venous thromboembolism after hospital discharge. Medication Adherence after Patient Education Medication adherence to clinician-ordered pharmacological venous thromboembolism prophylaxis was higher after the patient education program than in our historical cohort (94.4% vs 89.9%, P.0001) (Table 4). The proportion of patients receiving 100% of scheduled doses of injectable was higher after our novel patient education program Table 3 Characteristics of Patient Education Patient education provided within 24 hours of first 525 (99.4) thromboprophylaxis dose, Patient with questions about venous 18 (3.4) thromboembolism risk and thromboprophylaxis, Numbers of questions asked, (96.6) 1 15 (2.9) 2 3 (0.6) Most frequent topics resulting in patient questions, Risk of venous thromboembolism after hospital 7 (33.3) discharge Role of aspirin in venous thromboembolism 4 (19) prevention Bleeding risk with thromboprophylaxis 2 (9.5)

5 262 The American Journal of Medicine, Vol 125, No 3, March 2012 Table 4 Medication Adherence after Patient Education 100% thromboprophylaxis adherence, 389 (73.7) Number of doses scheduled 4392 Number of doses administered 4145 Number of doses omitted 287 Medication adherence*, % 94.4 No doses refused, 485 (91.9) Reasons for omitted doses, Patient refusal 84 (29.3) Held per responsible provider 39 (13.6) Patient off floor/unit 33 (11.5) Patient unable to receive 2 (0.7) Medication not available 1 (0.3) Thromboprophylaxis order discontinued 5 (1.7) Other 76 (26.5) *Medication adherence is calculated as number of doses administered divided by the number of doses scheduled. than in our historical cohort (73.7% vs 62.4%, P.001). Patient refusal as a reason for omitted doses was less frequent after the patient education program (29.3% vs 43.7%, P.001). In the patient education cohort, medication adherence was significantly higher for dalteparin than unfractionated heparin (96.4% vs 93.8%, P.002). The proportion of patients receiving 100% of scheduled doses of injectable also was significantly higher for dalteparin than unfractionated heparin (87.3% vs 62.4%, P.0001). The rate of patient refusal as a reason for omitted doses was similar for dalteparin and unfractionated heparin (35.3% vs 28.5%, P.41). Medication adherence was similar for low-molecularweight heparin (96.4% vs 94.9%, P.14) and higher for unfractionated heparin (93.8% vs 87.6%, P.0001) after the patient education intervention, compared with the historical control. The proportion of patients receiving 100% of scheduled doses of injectable pharmacological venous thromboembolism prophylaxis was higher for low-molecular-weight heparin (87.3% vs 77.6%, P.02) and unfractionated heparin (62.4% vs 47.2%, P 0.004) after the patient education intervention, compared with the historical control. The rate of patient refusal as a reason for omitted doses was similar for low-molecularweight heparin (35.3% vs 39.4%, P.2) and lower for unfractionated heparin (28.5% vs 44.5%, P.049) after the patient education intervention, compared with the historical control. Outcomes after Patient Education Symptomatic nonfatal venous thromboembolism at 90 days occurred in 1.3% of patients after the patient education program (Table 5). Death during hospitalization occurred in less than 1% of patients, while death at 90 days after the patient education program was observed in 4%. The majority of deaths were attributable to cancer and other noncardiovascular and non-cancer-related causes. No deaths were attributable to venous thromboembolism. Major bleeding events were rare (0.4%). DISCUSSION We found that a pharmacist-led individualized patient education program resulted in significantly higher medication adherence to clinician-ordered injectable pharmacological venous thromboembolism prophylaxis than in our historical cohort. The patient education program was associated with a one-third lower frequency of patient refusal as a reason for omitted doses of clinician-ordered injectable prophylactic anticoagulation. We found that the pharmacist-led patient education program was feasible, with 99% of sessions successfully completed within 24 hours of the initial order for prophylactic anticoagulation. We observed that medication adherence was significantly higher with once-daily subcutaneous low-molecularweight heparin than with twice-daily or 3-times-daily subcutaneous unfractionated heparin. In 2011, the US Surgeon General and the National Consumers League launched the Script Your Future campaign 17 to educate patients about the critical importance of medication adherence. Improving a patient s understanding of the rationale for prescribing a certain drug by explaining its benefits increases medication adherence. 18,19 For example, direct patient education interventions have been shown to improve medication adherence to beta-blocker therapy after myocardial infarction 20 and medical therapy for hypertension and dyslipidemia. 21 In the current study, our pharmacist-led patient education intervention achieved an absolute 5% higher rate of medication adherence to clinician-ordered injectable pharmacological venous thromboembolism prophylaxis. The significantly higher rate of medication adherence was largely due to a one-third lower frequency of patient refusal of clinician-ordered injectable Table 5 Outcomes after Patient Education Death during hospitalization, 4 (0.8) Death at 90 days, 23 (4.4) Cause of death*, Cardiovascular 3 (13) Cancer 10 (43.5) Other 10 (43.5) Major bleeding event at 90 days, 2 (0.4) Symptomatic venous thromboembolism at 90 days, 7 (1.3) Nonfatal deep vein thrombosis 3 (42.9) Nonfatal pulmonary embolism 4 (57.1) Non-bleed-related adverse drug reaction resulting in 2 (0.4) discontinuation of thromboprophylaxis, *No deaths were attributable to venous thromboembolism.

6 Piazza et al Patient Education for Thromboprophylaxis 263 prophylactic anticoagulation, especially for unfractionated heparin. These data suggest that patient education programs may play an important role in improving venous thromboembolism prevention efforts among hospitalized patients. We found that a pharmacist-led patient education program for improvement of medication adherence to clinician-ordered pharmacological venous thromboembolism prophylaxis in hospitalized patients was feasible. Patient education sessions were completed successfully within 24 hours of the initial order for prophylactic anticoagulation in 99% of patients. Of note, implementation of health care provider-based bedside patient education programs to improve medication adherence to venous thromboembolism prophylaxis is likely to be resource intensive for many medical centers. However, our observation that only 3% of patients took advantage of the questionand-answer component of the educational session suggests that a more resource-conservative computer-based (nonhuman) patient education strategy could be an effective alternative. Computer-based approaches, in particular, electronic alerting strategies, have been shown to be effective for educating health care providers about the importance of venous thromboembolism prophylaxis. 9-11,22-24 Similar to our historical cohort analysis, 13 we observed that medication adherence to clinician-ordered was greater for once-daily low-molecular-weight heparin than twice-daily or 3-times-daily unfractionated heparin. In the current study, patients prescribed low-molecularweight heparin refused fewer doses and were more likely to receive 100% of their scheduled doses than those ordered for unfractionated heparin. We speculate that patients may be more likely to refuse multiple daily doses of an injectable prophylactic anticoagulant than a single daily dose because of injection site discomfort or inconvenience. Medication adherence is an important consideration in selecting agents for thromboprophylaxis. New injectable agents for venous thromboembolism prophylaxis, such as the ultra low-molecular-weight heparin semuloparin, 25 should be evaluated in terms of safety, efficacy, and medication adherence. Compared with our historical cohort, 13 the patients in the current study were younger (58 years vs 64 years) and more frequently male (41.9% vs 25.6%). The risk of venous thromboembolism as estimated by our previously validated venous thromboembolism risk score 9,11 was similar in both the historical cohort and the current study (median venous thromboembolism risk score 4 vs 3). However, the historical cohort appeared to represent a more medically ill population with a higher frequency of cancer (70% vs 21%) and greater 90-day mortality (16.8% vs 4.4%) than in the current study. Our findings must be interpreted in the context of the study design. We cannot exclude the possibility that differences between the 2 study populations could have influenced medication adherence. We did not include patients who may have been ineligible for prophylactic anticoagulation and were prescribed graduated compression stockings or pneumatic compression devices. Therefore, we were not able to assess the impact of our patient education intervention on adherence to mechanical venous thromboembolism prophylaxis. Finally, our pharmacist-led patient education program was labor and resource intensive. Therefore, it may not be feasible at other medical centers. This may be the first study to demonstrate the impact of a patient education program for improving medication adherence to clinician-ordered pharmacological venous thromboembolism prophylaxis. Furthermore, our findings emphasize the importance of patient education in the context of a multidisciplinary pharmacist-physician approach to venous thromboembolism prevention. Our study population is derived from a tertiary care center that is representative of other similar acute care facilities. Finally, we obtained complete follow-up data for 100% of the study patients. Conclusions A pharmacist-led individualized patient education program resulted in a significantly higher rate of medication adherence to clinician-ordered injectable pharmacological venous thromboembolism prophylaxis. The higher rate of medication adherence was largely due to a one-third lower frequency of patient refusal of clinician-ordered injectable prophylactic anticoagulation. 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Cardiovascular Disease Educational and Research Trust; Cyprus Cardiovascular Disease Educational and Research Trust; European Venous Forum; International Surgical Thrombosis Forum; International Union of Angiology; Union Internationale de Phlébologie. Prevention and treatment of venous thromboembolism. International Consensus Statement (guidelines according to scientific evidence). Int Angiol. 2006;25: Amin A, Stemkowski S, Lin J, Yang G. Thromboprophylaxis rates in US medical centers: success or failure? J Thromb Haemost. 2007;5: Kahn SR, Panju A, Geerts W, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res. 2007;119:

7 264 The American Journal of Medicine, Vol 125, No 3, March Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371: Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005; 352: Fiumara K, Piovella C, Hurwitz S, et al. Multi-screen electronic alerts to augment venous thromboembolism prophylaxis. Thromb Haemost. 2010;103: Piazza G, Rosenbaum EJ, Pendergast W, et al. Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients. Circulation. 2009;119: Piazza G, Goldhaber SZ. Improving clinical effectiveness in thromboprophylaxis for hospitalized medical patients. Am J Med. 2009;122: Fanikos J, Stevens LA, Labreche M, et al. Adherence to pharmacological thromboprophylaxis orders in hospitalized patients. Am J Med. 2010;123: An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med. 1993;329: Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med. 1998;129: Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354: National Consumers League. Script your future; Available at: Accessed June 16, Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119: Baroletti S, Dell Orfano H. Medication adherence in cardiovascular disease. Circulation. 2010;121: Smith DH, Kramer JM, Perrin N, et al. A randomized trial of directto-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. 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J Clin Oncol. 2011;29 (suppl); abstr LBA9014. APPENDIX Educational Script What is venous thromboembolism? By being in the hospital, in combination with other risk factors, you are at an increased risk for developing a blood clot known as deep vein thrombosis that usually forms in the legs or occasionally in other veins such as in your arms, chest, or pelvic area. Sometimes, clots can break off from the walls of the vein and travel to your lungs. This is called pulmonary embolism. Pulmonary embolism can be a lifethreatening condition. What does the medication do? Your doctor has prescribed for you to receive preventivedose injections (of heparin, dalteparin, or fondaparinux) (once, twice, or three times daily). This medication helps prevent blood clots from developing. It is in a class called the anticoagulants, which are sometimes referred to as blood thinners. These injections have been shown in many clinical trials and in day-to-day clinical practice to be extremely successful at lowering the risk for developing a clot while you are in the hospital. They also have an outstanding safety record. These anticoagulants have been given in low doses to prevent blood clots in millions of patients. In these low doses, they rarely cause bleeding problems. Why is it important to take every dose? It is important that you take every dose of this medication. (Heparin, dalteparin, or fondaparinux) is scheduled to be given (once, twice, or three times daily) to ensure that you have protection from clot formation throughout the whole day. Once the medication effects wear off, you have the same risk as if you were not taking the medication until you receive your next dose. Even though there is some discomfort that may go along with these injections, it is often minor compared to the consequences of a deep vein thrombosis or pulmonary embolism. The injections will continue only for as long as your doctor feels you remain at risk. Conclusion In summary, I hope you will continue to receive all of your scheduled injections. Do you have any questions at this time about blood clots or your medications? If you do have any further questions or concerns, I can be reached by phone at (number).