Conformance of clinical practice to established recommendations for the diagnosis and treatment of venous thromboembolic disease: Robin revisited.

Abstract

Over a decade ago, Dr. Robin expressed concern regarding overdiagnosis and overtreatment of pulmonary embolism. Since that time, significant advances have been forthcoming in the diagnosis and treatment of venous thromboembolic disease. Using Continuous Quality Improvement concepts, this study revisits Robin's concerns and assesses the conformance of clinical practice at one institution with established requirements for the diagnosis and treatment of venous thromboembolic disease to identify remaining opportunities to improve care. The study design is a retrospective chart review. Medical records of all patients (N = 63) discharged from a university-affiliated teaching hospital from 7/1/89 to 6/30/90 with a diagnosis of primary venous thromboembolic disease were studied. Requirements for the diagnosis and treatment were established through review of the medical literature. Conformance to these requirements was assessed and described. Descriptive statistics were used. Only 7 of 63 charts (11%) met all requirements for the diagnosis and treatment of venous thromboembolic disease. Fifty-six charts (89%) failed to meet at least one criterion. There was no evidence of overdiagnosis of venous thromboembolic disease in patients with a discharge diagnosis of pulmonary embolism (N = 17). Eight of 62 patients (13%) demonstrated potential overdiagnosis of venous thromboembolic disease involving the lower extremities. Nine of 60 (15%) heparin therapies demonstrated significant nonconformance to recommendations. Fifty-four of 59 (91%) warfarin therapies failed to conform to recommendations. Eighty-three percent of these warfarin errors were considered to be technical. However, 17% were determined to be clinically significant. Of 5 patients treated with a transvenous filter device, 1 failed to meet therapeutic requirements. No patients received thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)