Comparison of Venothromboembolism Prophylaxis Practices in a Winnipeg Tertiary Care Hospital to Chest Guidelines: A Quality Improvement Project Dr. Jonathan Laxton, FRCPC, R5 GIM University of Manitoba November 16, 2013
Disclosure Once ate a muffin at a drug-company sponsored talk post-call and have felt guilty ever since Otherwise no competing interests
Objectives Demonstrate how current VTE prophylaxis practices on MTU ward corresponds to current ACCP guidelines Generate thought and discussion on more critical use of VTE prophylaxis can be promoted on MTUs
The Problem Pulmonary embolism (PE) leading preventable cause (5-10%) in-hospital death 1 70-80% of these in medical patients 2 Appropriate prophylaxis can decrease risk 50-67% 3-4 Pharmacological prophylaxis increases risk of bleeding 4 1 Alikhan, R. et al. (2004). Fatal pulmonary embolism in hospitalised patients: a necrospy review. Journal of Clinical Pathology, 57: 1254-7 2 Cohen, A.T., et al. (2005). Assessment of venous thromboembolism risk and benefits of thromboprophylaxis in medical patients. Journal of Thrombosis & Haemostasis, 94 (4): 750-9. 3 Dentali, F., et al. (2007). Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalised medical patients. Annals of Internal Medicine, 146 (4): 278-88 4 Lloyd, N.S., et al., (2008). Anticoagulant prophylaxis to prevent asymptomatic deep venous thrombosis in hospitalised medical patients: a systematic review and meta-analysis. Journal of Thrombosis and Haemostasis, 6 (3): 405-14.
New Guidelines American College of Chest Physicians proposed using Padua Prediction score 5 5 Kahn, S.R., et al. (2012). Prevention of VTE in non-surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141: 195-226. Risk Factor Points Previous VTE 3 Active Cancer 3 Reduced mobility 3 Known thrombophilia 3 Recent trauma and/or surgery 2 Elderly ( 70yo) 1 Heart and/or respiratory failure Acute MI and/or stroke 1 Acute infection and/or rheumatologic condition Obesity (BMI 30) 1 Ongoing hormonal treatment 1 1 1
Validity of Prediction Score 6 Observational study 1180 medical inpatients 90 days duration High risk patients (score 4) 39.7% patients VTE rate 11% Low risk patients (score <4) 60.3% patients VTE rate 0.3% (many had active cancer) 6 Barbar, S., et al. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis & Haemostasis, 8: 2450-7
Reason for Project To assess how well current practice corresponds to guidelines If poor correspondence, then to assess need for a decision aid to be built-in with admission process (i.e. EMR prompt) And mandated at accreditation
Objectives Quality improvement project. 3 major objectives: 1. Determine current VTE prophylaxis practices 2. Compare current practices to new ACCP guidelines 3. See if ACCP recommendations are feasible as basis for hospital policy.
Study Design Observational project Note researcher on night float. Patients admitted to medicine over two weeks Excluded patients on full anticoagulation Following variables assessed: 1.Administration of VTE prophylaxis 2.Variables to calculate Padua score 3.Any thrombotic events 4.Any major bleeding events 7 7 Schulman, S., & Kearon, C. (2005). Definition of major bleeding in clinical investigations of antihaemostatic medical products in nonsurgical patients. Journal of Thrombosis & Haemostasis, 3 (4): 692-4.
Sample Description 169 patients assessed 32 excluded (anticoagulation) 137 patients total in study Characteristic Value Average Age 69.5 (21-100yrs) Male 57 (41.6%) Female 80 (58.4%) High Risk 68 (49.6%) Low Risk 69 (50.4%)
Results by Prophylaxis Status Parameter VTE Prophylaxis No VTE Prophylaxis P-value Total (%) 93 (67.9) 44 (32.1) N/A Male 35 (61.4) 22 (38.6) 0.09 Female 56 (70.0) 24 (30.0) 0.0003 Average Age (range) 69.4 (33-100yrs) 63.8 (21-89yrs) 0.005 High Risk (%) 53 (77.9) 15 (22.1) N/A Low Risk (%) 38 (55.1) 31 (44.9) N/A Average Score 3.5 ± 1.6 2.4 ± 2.0 0.0008 Bleeding Event 1 1 N/A Thrombotic Event 0 0 N/A
Notes About the Data No significant change when researcher-admitted patients removed. All prophylaxis was with unfractionated heparin (UFH) subcutaneously High risk score: 5 presented with bleeding 3 of these received no prophylaxis No pneumatic compression devices (PCD) used. Low risk score: Classified 3 patients with active cancer as low risk
Objective 1: Current Practices UFH subcutaneously is used by far the most Prophylaxis was appropriately not universally applied 2 patients with active cancer (and no bleeding) did not receive prophylaxis. PCD not used on high risk patients with bleeding 5,8 8 Qaseem, A., et al. (2011). Venous thromboembolism prophylaxis in hospitalised patients: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine, 155: 625-32.
Objective 2: Comparison to ACCP Guidelines Significantly more patients with higher Padua score received prophylaxis Larger proportion high risk patients received prophylaxis. A large number of low risk individuals exposed to prophylaxis.
MTU Practice Erred towards over-prophylaxis Potential reasons: Lack of awareness of guidelines Previous heavy emphasis on prophylaxis (used as quality indicator for a hospital) Confusion moving from surgical to medical wards and difference in prophylaxis needs Tendency to automatically just check it off on admission if not bleeding
Objective 3: Potential Decision Support Tool Simpler method needed Also should consider bleeding risk Several Problems with Padua Score: No assessment of bleeding risk Cumbersome to apply Difficult to remember Classified some active cancers as low risk
Limitations Potential bias from researcher admitting patients Not powered or long enough for VTE or bleeding events Missing some data to compare other risk stratification approaches (IMPROVE, ACP guidelines) 8,9 9 Spyropoulos, A.C., et al. (2011). Predictive and associative models to identify hospitalised medical patients at risk for VTE. Chest, 140: 706-14.
Future Directions Some ideas to test for improving evidencebased practice in medical VTE prophylaxis: Include evidence-based score in admission orders for prophylaxis decision support Education session on prophylaxis guidelines Purposefully making it a teaching issue on each or selected patients 9 Spyropoulos, A.C., et al. (2011). Predictive and associative models to identify hospitalised medical patients at risk for VTE. Chest, 140: 706-14.
Future Directions Potentially easier evidence-based system for future project: Prophylaxis >40yo immobilised for 3 days with 1 risk factor for VTE 10 <40yo if previous VTE, known thrombophilia with positive family history or active cancer. Bleeding (most significant )11 Active gastroduodenal ulcer Bleeding in last 3mo Platelets <50 Compare 2 wards or before/after policy design Policy encourage PCD if high risk of both bleeding and VTE 5,8 10 Francis, C.W. (2007). Clinical Practice. Prophylaxis for thromboembolism in hospitalised medical patients. New England Journal of Medicine, 356 (14): 1438. 11 Decousus, H., et al. (2010). Factors at admission associated with bleeding risk in medical patients: Findings from the IMPROVE investigators. Chest, 139: 69-79.
References 1. Alikhan, R. et al. (2004). Fatal pulmonary embolism in hospitalised patients: a necrospy review. Journal of Clinical Pathology, 57: 1254-7 2. Cohen, A.T., et al. (2005). Assessment of venous thromboembolism risk and benefits of thromboprophylaxis in medical patients. Journal of Thrombosis & Haemostasis, 94 (4): 750-9. 3. Dentali, F., et al. (2007). Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalised medical patients. Annals of Internal Medicine, 146 (4): 278-88 4. Lloyd, N.S., et al., (2008). Anticoagulant prophylaxis to prevent asymptomatic deep venous thrombosis in hospitalised medical patients: a systematic review and meta-analysis. Journal of Thrombosis and Haemostasis, 6 (3): 405-14. 5. Kahn, S.R., et al. (2012). Prevention of VTE in non-surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141: 195-226. 6. Barbar, S., et al. (2010). A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. Journal of Thrombosis & Haemostasis, 8: 2450-7 7. Schulman, S., & Kearon, C. (2005). Definition of major bleeding in clinical investigations of antihaemostatic medical products in non-surgical patients. Journal of Thrombosis & Haemostasis, 3 (4): 692-4. 8. Qaseem, A., et al. (2011). Venous thromboembolism prophylaxis in hospitalised patients: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine, 155: 625-32. 9. Spyropoulos, A.C., et al. (2011). Predictive and associative models to identify hospitalised medical patients at risk for VTE. Chest, 140: 706-14. 10. Francis, C.W. (2007). Clinical Practice. Prophylaxis for thromboembolism in hospitalised medical patients. New England Journal of Medicine, 356 (14): 1438. 11. Decousus, H., et al. (2010). Factors at admission associated with bleeding risk in medical patients: Findings from the IMPROVE investigators. Chest, 139: 69-79.