Expert Commentary on Venous Thromboembolism Prophylaxis after Surgery in Patients With Inflammatory Bowel Disease.

Review question/objective The objective of this review is to identify, appraise and synthesise the best available evidence on the facilitators and barriers to compliance with Venous Thromboembolism (VTE) risk assessment and prophylaxis clinical practice guidelines in the acute care setting. More specifically, the review question is: To what extent are clinical practice guidelines for risk assessment and prophylaxis of VTE adhered to in the acute care setting, and what are the facilitators and barriers? Inclusion criteria Types of participants This review will consider any studies that include all health care professionals regardless of their designated involvement with venous thromboembolism risk assessment and prophylaxis in the acute care setting. Phenomena of interest This review will consider studies that evaluated the facilitators and barriers to venous thromboembolism compliance with clinical practice guidelines in the acute care setting. The qualitative component of the review will consider as phenomena of interest any studies that identify facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The quantitative component of the review will consider any studies that report on the barriers and facilitators to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The textual component of the review will consider any paper that discusses the facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. Types of outcomes This review will consider studies that include measures of compliance as their outcome measures. The qualitative component of the review will consider any studies that identify facilitators and/or barriers to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The quantitative component of the review will consider any studies that report on the barriers and facilitators to compliance with clinical practice guidelines in relation to venous thromboembolism risk assessment and prophylaxis in the acute care setting. The textual component of the review will consider any paper TRUNCATED AT 350 WORDS

Venous Thromboembolism Risk Assessment and Prophylaxis: A Comprehensive Systematic Review of the Facilitators and Barriers to Healthcare Worker Compliance with Clinical Practice Guidelines in the acute care setting.

ObjectiveWe set out to determine the rate of pharmacological venous thromboembolism (VTE) prophylaxis among patients admitted with inflammatory bowel disease (IBD) and indirectly compare it to national trends. We also assessed the demographic and clinical correlates for non-prescription of pharmacologic VTE prophylaxis among IBD patients with and without a flare.MethodsWe extracted data from 123 patients admitted to our facility with IBD from September 2018 to August 2020 retrospectively. Out of this cohort, 26 patients were excluded and 96 were included in our analysis. Baseline characteristics were analyzed using descriptive statistics. Multiple logistic regression was used to evaluate the correlates of pharmacological VTE prophylaxis use in individuals with IBD and to analyze the predictors of VTE prophylaxis use in patients with IBD flares.ResultsOut of the 96 patients with IBD included in this study, 61 (63.5%) presented with an IBD flare, and among those with a flare, 26/61 (42.6%) received VTE prophylaxis. IBD patients aged ≥ 65 years and of Black race were less likely to be placed on pharmacological VTE prophylaxis (adjusted odds ratio (AOR) 0.20, 95% CI (0.06 - 0.70), p-value 0.012) and (AOR 0.16, 95% CI (0.05 - 0.50), p-value 0.002) respectively. Among those with a flare, the presence of bright red bleeding per rectum was associated with a low rate of pharmacologic VTE use (AOR 0.01, 95% CI (0.00 -1.78), p-value 0.001). Overall the rate of VTE prophylaxis use in the IBD patient cohort was 56.3% and this was irrespective of flare status.ConclusionOur study showed the low rate of pharmacologic VTE prophylaxis use in IBD patients at this center and this finding was in line with national trends. Interestingly age and the race of patients played a major role in the decision to provide pharmacological VTE prophylaxis but the reason for this finding was not explored by our study. A larger multi-center study is needed to further evaluate these relationships.

Despite increased risk of venous thromboembolism (VTE) among hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis rates remain low. We sought to understand the reasons for this by assessing factors associated with VTE prophylaxis in patients with IBD and the safety of its use. This was a retrospective cohort study conducted among patients hospitalized between January 2013 and August 2018. The primary outcome was VTE prophylaxis, and exposures of interest included acute and chronic bleeding. Medical records were parsed electronically for covariables, and logistic regression was used to assess factors associated with VTE prophylaxis. There were 22,499 patients studied, including 474 (2%) with IBD. Patients with IBD were less likely to be placed on VTE prophylaxis (79% with IBD, 87% without IBD), particularly if hematochezia was present (57% with hematochezia, 86% without hematochezia). Among patients with IBD, admission to a medical service and hematochezia (adjusted odds ratio 0.27; 95% CI, 0.16-0.46) were among the strongest independent predictors of decreased VTE prophylaxis use. Neither hematochezia nor VTE prophylaxis was associated with increased blood transfusion rates or with a clinically significant decline in hemoglobin level during hospitalization. Hospitalized patients are less likely to be placed on VTE prophylaxis if they have IBD, and hematochezia may drive this. Hematochezia appeared to be minor and was unaffected by VTE prophylaxis. Education related to the safety of VTE prophylaxis in the setting of minor hematochezia may be a high-yield way to increase VTE prophylaxis rates in patients with IBD.

Inflammatory bowel disease (IBD) patients are at an increased risk of thrombosis, particularly when hospitalized. Several clinical practice guidelines now recommend pharmacologic prophylaxis for hospitalized ulcerative colitis and Crohn's disease patients. It is unclear to what extent gastroenterologists are aware of these recommendations and whether they are administering pharmacologic venous thromboembolism (VTE) prophylaxis appropriately. Our aim was to explore current practice of VTE prophylaxis in hospitalized IBD patients in the United States. A survey was mailed electronically to gastroenterologists whose electronic mail address was listed in the American College of Gastroenterology (ACG) database. This survey included clinical vignettes outlining scenarios for consideration of VTE prophylaxis. A total of 6227 surveys were sent to gastroenterologists nationwide, and 591 physicians chose to participate (response rate 9.5%). Respondents (80.6%) believed that hospitalized IBD patients have a higher risk of VTE than other inpatients. A total of 29.1% were unaware of any recommendations addressing pharmacologic prophylaxis included in ACG IBD guidelines and 34.6% would give pharmacologic VTE prophylaxis to a hospitalized patient with severe ulcerative colitis. Heparin VTE prophylaxis use was associated with gastroenterologists who indicated that their practices comprised more than 50% of patients with IBD (P=0.0001), being a physician at an academic hospital (P=0.0001) and providers having less than 5 years practice experience (P=0.003). Despite reasonable awareness of the increased risk of thrombosis in hospitalized IBD patients, many US gastroenterologists may not follow clinical practice guidelines and use pharmacologic VTE prophylaxis.

BACKGROUND: Venous Thromboembolism (VTE) in hospitalized Inflammatory Bowel Disease (IBD) patients increases length of stay by 48% and leads to a 59% increase in hospital charges1. Analyses show30% of gastroenterologists are unaware of ACG guidelines for VTE prophylaxis in hospitalized IBD patients; only 34% reported they would give prophylaxis to patients with an active flare2. We hypothesize that we under-prescribe prophylaxis in IBD patients due to misguided fear of poor outcomes such as bleeding. Our primary objective is to determine if Lankenau Medical Center adheres to guidelines set forth by gastroenterology societies as well as the American College of Chest Physicians in implementing VTE prophylaxis among hospitalized IBD patients. METHODS: We conducted a retrospective cohort study reviewing inpatient medical records for admissions to Lankenau Medical Center from January 1st, 2009 to December 31st, 2014 with an ICD diagnosis of IBD. Patients were evaluated regardless of admitting diagnosis. Exclusion criteria included age <18 and >90, and patients on long term systemic anticoagulation for any reason, including those with a history of VTE. We subsequently excluded charts from 2009 secondary to a lack of data within the electronic medical record. We collected data on IBD diagnosis (UC vs Crohns), and choice of VTE prophylaxis including enoxaparin, unfractionated heparin, sequential compression devices, Aspirin 81mg BID or none. Additional variables were collected for future analysis. We categorized VTE prophylaxis on admission as follows: a.) Appropriate VTE prophylaxis with heparin or Lovenox; b.) Inappropriate VTE prophylaxis, with sequential compression devices or aspirin; or c.) No VTE prophylaxis. RESULTS: 568 inpatient charts were evaluated. 182 of these met exclusion criteria; 386 were included. 99% (N=384) had a confirmed diagnosis of Crohn's disease while 1% (N=4) had Ulcerative Colitis. 49% of patients were placed on appropriate pharmacologic VTE prophylaxis (N= 189). Subcutaneous heparin was implemented in 12% while 37% were started on enoxaparin. The remaining 50% of our population was started on either inappropriate VTE prophylaxis or no prophylaxis at all. Of those started on inappropriate VTE prophylaxis on admission 20% received sequential compression devices while 2% received twice daily aspirin therapy. 27% of our study population was not started on any VTE prophylaxis on admission. CONCLUSION(S): Appropriate VTE prophylaxis in hospitalized IBD patients has been shown to decrease morbidity, length of stay, and cost. Nevertheless, even experts remain unaware of guideline recommendations for VTE prophylaxis in this population. We showed that our institution is currently falling short of recommendations. Further analysis will determine any significant variables influencing use of VTE prophylaxis in the 50% of our population with inadequate therapy; we hope to define the barriers to VTE prophylaxis initiation, in order to develop a comprehensive intervention to improve our compliance with these guidelines.

INTRODUCTION: Inflammatory Bowel Disease (IBD) is comprised of two distinct disorders: Crohn’s Disease (CD) and Ulcerative Colitis (UC). They are chronic inflammatory diseases that primarily affect the gastrointestinal (GI) tract, but they can also cause extraintestinal complications. Venous thromboembolism (VTE) is particularly prevalent in IBD patients (IBDP), especially during disease flares, and is associated with high risk of morbidity and mortality. However, IBDP also have a propensity for GI bleeding during IBD exacerbations. With risk for both VTE and GI bleed, the decision to start VTE prophylaxis (VTEP) in hospitalized IBD patients poses a conundrum. The American College of Chest Physicians currently recommends such patients receive VTEP as data from numerous randomized controlled trials demonstrates VTEP is not associated with major adverse events in IBDP. The goal of this study was to evaluate the rate of VTEP at our hospital. METHODS: A retrospective chart review was conducted following all IBDP admitted to Wake Forest Baptist Medical Center from 1/2019 to 6/2019. 150 patients were identified. Demographics, admission diagnosis, admission medications, presenting symptoms, and medical history were collected. RESULTS: Of the 150 IBDP, 57% received VTEP on admission. In admissions related to IBD (37%), 18.2% received VTEP, whereas in non-IBD related complaints 79% received VTEP. Among patients endorsing hematochezia on admission (15%), 22% received VTEP. Of the patients with a history of GI bleed (65%), 47% received VTEP. 50% of patients with a history of VTE (12%), received VTEP. Odds ratio estimates showed IBD related admissions, hematochezia, and history of GI bleed were negatively associated with VTEP. CONCLUSION: Our analysis demonstrated a statistically significant decrease in administration of VTEP in patients admitted for an IBD related complaint, patients endorsing hematochezia, and patients with a history of GI bleed. This shows a major deficit in our hospital’s adherence to the ACCP guidelines of VTEP administration to all IBDP admitted to the hospital. Future directions of these findings include implementation of a Best Practice Advisory (BPA) into the electronic medical record to encourage VTEP for IBDP. After a trial of this BPA, a similar analysis will be repeated to evaluate the efficacy of the measure.Figure 1

Pharmacologic Prophylaxis for Venous Thromboembolism Among Hospitalized Patients with Acute Medical Illness: An Electronic Medical Records Study

Utilization of pharmacologic venous thromboembolism (VTE) prophylaxis in inflammatory bowel disease (IBD) patients seems to be suboptimal with reported rates as low as 50% in some studies. Implementation of an electronic alert system seems to be an effective tool for increasing VTE prophylaxis rates in medical inpatients. To date, no studies have assessed whether this approach is associated with improved rates of pharmacologic VTE prophylaxis specifically in IBD patients. To determine the efficacy of an electronic alert in improving VTE prophylaxis rates in hospitalized IBD patients. We conducted a retrospective cohort study of 576 hospitalized IBD patients. The medical record of each patient was then examined to determine whether pharmacologic VTE prophylaxis was both ordered and administered, the timing of pharmacologic VTE prophylaxis, and reasons for any missed doses. The VTE pharmacologic prophylaxis rate was improved from 60% to 81.2% following the implementation of the electronic alert system (p < .001). An increase in prophylaxis rates was seen in both medical (26.3% vs. 62.8%, p < .001) and surgical services (83.7% vs. 95.5%, p < .001). In patients who received pharmacologic VTE prophylaxis, 16% of all ordered doses were not administered and 57.3% of missed doses were the result of patient refusal. Hospitalization after implementation of the electronic alert system (odds ratio [OR] 4.71, 95% confidence interval [CI] 2.94-7.57) and admission to a surgical service (OR 14.3, 95% CI 8.62-24.39) were predictive of VTE pharmacologic prophylaxis orders. The introduction of an electronic alert system was associated with a significant increase in rates of pharmacologic VTE prophylaxis. However, orders were often delayed and doses not always administered. The most common reason that ordered doses were not given was patient refusal.

The American Society of Colorectal Surgeons (ASCRS) recently endorsed low-molecular-weight heparin and low-dose heparin as primary prophylaxis for venous thromboembolism (VTE) in highest-risk patients. Our study evaluates the feasibility of sequential compression device (SCD) use for VTE prophylaxis in these patients. Computerized databases of discharge diagnoses from three hospitals were reviewed. All patients with colorectal cancer or inflammatory bowel disease during a 7-year period were identified. Those who underwent major abdominal surgery and received VTE prophylaxis exclusively with SCDs were selected for the study. Patients diagnosed with postoperative VTE were identified through review of the three databases and of patient records for 90 days after surgery. One thousand two hundred eighty-one patients classified as highest-risk under the published ASCRS parameters underwent major abdominal surgery and received SCDs perioperatively. The incidence of clinically detectable postoperative VTE was 0.78 per cent. There were trends toward lower incidence among patients with malignancy (0.53%) compared with inflammatory bowel disease (1.48%, P = 0.09), and those with abdominal compared to pelvic procedures (0.62% vs. 1.04%, P = 0.41). Prophylaxis for perioperative VTE solely with SCD is a viable option for patients classified as highest-risk under ASCRS parameters.

Introduction: Patients with inflammatory bowel disease (IBD) harbor a higher risk of deep venous thrombosis and venous thromboembolism (VTE) compared to healthy individuals. Previous studies, including a large meta-analysis, estimate the risk of VTE incidence to be almost 2-3 times baseline. Guidelines, therefore, recommend VTE prophylaxis in most inpatients with IBD. While previous studies have demonstrated less than ideal adherence with these guidelines, we sought to determine the rate of VTE prophylaxis at an academic medical center. Methods: A retrospective chart review of inpatients with Crohn’s disease or ulcerative colitis admitted to a tertiary medical center in Bronx, NY from 1/2015 to 2/2020 was performed. All patients who were admitted with a primary gynecological or psychiatric disorder, COVID infection, or known hypercoagulable disorder were excluded. Orders for pharmacologic and mechanical VTE prophylaxis at any point during the patient’s admission were abstracted. Using ICD10 codes, IBD patients with acute VTE variations were identified. Clinical and demographic variables were analyzed for their association with VTE prophylaxis. Two-sample t-tests and Fisher’s exact tests were used as appropriate. A p-value < 0.05 was considered statistically significant. Results: A total of 1670 patients with IBD were identified among whom 1280 (76.7%) were prescribed either pharmacological or mechanical VTE prophylaxis during their hospital admission. 70 patients were excluded from the analysis of development of VTE because their diagnosis of VTE was prior to their admission date. Older age (p< .0001), higher BMI (p< .0001), female sex (p=.001), having Medicare insurance (p< .0001) were associated with VTE prophylaxis ordering (see Table). There was a VTE incidence of 6.2% (n=98/1600) of the IBD patients in our cohort, with 3/388 patients (0.8%) not being prescribed prophylaxis and 95/1212 (7.8%) being prescribed prophylaxis (p< 0.001). Conclusion: Contrary to other studies, we show that VTE prophylaxis rates may not be associated with a reduction in VTE incidence during hospitalization. While bias by indication may be contributing to this finding with those at greatest risk more likely to receive prophylaxis, other factors may be involved. Further studies are warranted. Table 1. - VTE incidence rates and bivariate association of demographical variables with prophylaxis VTE Prophylaxis p-value Total (n) Yes No Demographics 1670 Age, mean (SD) 61.91 (19.85) 42.73 (24.39) < .0001 BMI, mean (SD) 28.11 (8.74) 25.60 (6.15) < .0001 Sex 0.001 Female 726 (56.7) 185 (47.4) Male 554 (43.3) 205 (52.6) Ethnicity 0.79 Hispanic 502 (39.2) 160 (41.0) Not Hispanic 662 (51.7) 194 (49.7) Unknown 116 (9.1) 36 (9.2) Insurance < .0001 CMO 5 (0.4) 0 (0) 0.60 Commercial 263 (20.6) 111 (28.5) 0.002 Medicaid 360 (28.1) 170 (43.6) < 0.0001 Medicare 615 (48.1) 91 (23.3) < 0.0001 Self-Pay 37 (2.9) 18 (4.6) 0.12 Outcome 1600 Developed VTE 95 (7.8) 3 (0.8) -

Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis

Background: Venous thromboembolism (VTE) is a preventable disease in hospitalized patients; however, VTE prophylaxis is underutilized. Effective strategies for the assessment of individual patients' VTE risk and the provision of VTE prophylaxis are needed. Objective: To evaluate the efficacy of a multidisciplinary intervention designed to improve VTE risk assessment and prophylaxis in at-risk hospitalized patients. Methods: The multidisciplinary intervention to improve VTE risk assessment and prophylaxis consisted of 3 strategies: a broad educational effort, nursing assessment, and pharmacist follow-up. Educational programs were delivered to nursing, pharmacy, and physician staff. Upon admission, all patients were assessed for VTE risk factors by nursing staff. Pharmacists reviewed reports of patients screened to have at least 1 VTE risk factor; for patients not prescribed VTE prophylaxis, pharmacists placed a progress note and VTE prophylaxis order form in the chart. If no prophylaxis was prescribed by the following day, the pharmacist contacted the physician with a verbal recommendation. The impact of this intervention was evaluated by comparing the proportion of patients assessed for VTE risk factors on admission and the proportion of VTE prophylaxis candidates who received prophylaxis, both before and after implementation. Results: A total of 310 patients were included during the 2-month study period. An increase in patients assessed for the presence of VTE risk factors was observed after the intervention (41% vs 87%, p &lt; 0.001). Similarly, an increase in patients prescribed prophylaxis was observed after the intervention (36% vs 63%, p &lt; 0.001). Conclusions: This multidisciplinary approach including education, nursing assessment, and pharmacist follow-up resulted in a significant increase in the rates of VTE risk assessment and prophylaxis.

469 Background: VTE is a serious complication in multiple myeloma patients, who have a 9-fold increased risk compared to the general population. Prophylaxis for VTE is recommended by international guidelines in multiple myeloma patients based on VTE risk assessment, but published studies have demonstrated prescribing may be suboptimal. Our aim was to evaluate the impact of integrating standardized VTE prophylaxis orders for multiple myeloma patients on active treatment into our EHR, which services over 2300 providers within 500 community cancer treatment locations across the United States. Methods: National Comprehensive Cancer Network Guideline-recommended VTE prophylaxis agents were integrated as optional orders into multiple myeloma EHR regimen templates from June to July 2022. Optional informational orders were also included: a “VTE Prophylaxis Reminder” order served as a trigger for the care team if prophylaxis was not prescribed and a “VTE Prophylaxis Exception” order served as documentation if the patient did not qualify for anticoagulation. An educational guide about VTE risk stratification and prophylaxis in multiple myeloma was developed and embedded in regimen templates. To evaluate the impact of this intervention, a structured EHR data export was used to identify multiple myeloma patients with regimen templates ordered during the prespecified time frames. A retrospective chart review was conducted to identify documentation of anticoagulation or reason for exception on or prior to cycle 1 day 1 of the multiple myeloma regimen. Data were compared using the Fisher’s exact test. We also evaluated ordering of VTE prophylaxis and use of informational orders from regimens during the post-implementation phase. Results: A total of 297 patients were identified, with 128 during the pre-implementation phase (May 2022) and 169 during the post-implementation phase (September 2022). Documentation of anticoagulation or reason for exception on or prior to cycle 1 day 1 of the multiple myeloma regimen increased from 70% (89/128) during the pre-implementation phase to 81% (137/169) during the post-implementation phase (two-sided p=0.0276). Aspirin was the most common agent prescribed in 73% and 64% of patients, respectively. During the post-implementation phase, VTE prophylaxis was prescribed directly from the regimen in 16% of patients. The “VTE Prophylaxis Reminder” order was utilized for 89% of patients and the “VTE Prophylaxis Exception” order was utilized for 1 patient. Conclusions: Integration of standardized orders into EHR regimen templates may facilitate prescribing and serve as reminders for the care team. We saw an 11% increase in documentation of VTE prophylaxis, which may potentially reduce risk of VTE in this patient population. Efforts are ongoing to highlight the need for anticoagulation and importance of documentation.

Hospitalized inflammatory bowel disease (IBD) patients are at a higher risk of venous thromboembolism (VTE). We aimed to determine perceptions of VTE risks and self-reported practices regarding VTE prophylaxis in hospitalized IBD patients among American gastroenterologists. Gastroenterologists who were members of the American Gastroenterological Association (AGA) and cared for IBD patients in the preceding 12 months were included. A survey assessed physicians' perceptions of VTE risks and their practices regarding VTE prophylaxis among IBD inpatients and other factors that may influence the decision to provide prophylaxis. A total of 135 eligible gastroenterologists responded to the survey, 77 % of whom practiced in academic settings. Most physicians (84%) reported having had IBD patients develop VTE. Only 67% cared for IBD patients in hospitals that had protocols for VTE prophylaxis, and 45% were aware of any published guidelines for VTE prophylaxis in hospitalized IBD patients. While only 7% believed that any rectal bleeding was a contraindication to VTE chemoprophylaxis in hospitalized IBD patients with flares, 14% never administered prophylaxis to IBD inpatients. A significant number of respondents felt that hospitalized IBD patients who were ambulatory (24%) or in remission (28%) did not require VTE prophylaxis. There was wide variation on recommendations for duration of anticoagulation for a first unprovoked VTE in an IBD patient. There is significant variation in reported practices for VTE prophylaxis in IBD patients among gastroenterologists. A more standardized approach to VTE prophylaxis should be implemented to improve health outcomes for IBD inpatients.