Multifaceted Intervention to Prevent Venous Thromboembolism in Patients Hospitalized for Acute Medical Illness: A Multicenter Cluster-Randomized Trial.

Pierre-Marie Roy,Dominique El Kouri,Dominique Mottier,Grégoire Le Gal,Prevenu Study Group ,Guy Meyer,Jeannot Schmidt,Jean-Marie Chrétien,Pierre Durieux,Pierre Hausfater,Catherine Legall,Antoine Rachas,Didier Honnart

doi:10.1371/journal.pone.0154832

Abstract

BackgroundMisuse of thromboprophylaxis may increase preventable complications for hospitalized medical patients.ObjectivesTo assess the net clinical benefit of a multifaceted intervention in emergency wards (educational lectures, posters, pocket cards, computerized clinical decision support systems and, where feasible, electronic reminders) for the prevention of venous thromboembolism.Patients/MethodsProspective cluster-randomized trial in 27 hospitals. After a pre-intervention period, centers were randomized as either intervention (n = 13) or control (n = 14). All patients over 40 years old, admitted to the emergency room, and hospitalized in a medical ward were included, totaling 1,402 (712 intervention and 690 control) and 15,351 (8,359 intervention and 6,992 control) in the pre-intervention and intervention periods, respectively.ResultsSymptomatic venous thromboembolism or major bleeding (primary outcome) occurred at 3 months in 3.1% and 3.2% of patients in the intervention and control groups, respectively (adjusted odds ratio: 1.02 [95% confidence interval: 0.78–1.34]). The rates of thromboembolism (1.9% vs. 1.9%), major bleedings (1.2% vs. 1.3%), and mortality (11.3% vs. 11.1%) did not differ between the groups. Between the pre-intervention and intervention periods, the proportion of patients who received prophylactic anticoagulant treatment more steeply increased in the intervention group (from 35.0% to 48.2%: +13.2%) than the control (40.7% to 44.1%: +3.4%), while the rate of adequate thromboprophylaxis remained stable in both groups (52.4% to 50.9%: -1.5%; 49.1% to 48.8%: -0.3%).ConclusionsOur intervention neither improved adequate prophylaxis nor reduced the rates of clinical events. New strategies are required to improve thromboembolism prevention for hospitalized medical patients.Trial RegistrationClinicalTrials.gov NCT01212393

Highlights

The rates of thromboembolism (1.9% vs. 1.9%), major bleedings (1.2% vs. 1.3%), and mortality (11.3% vs. 11.1%) did not differ between the groups
A recent meta-analysis has suggested that alerts or multifaceted interventions increase prophylaxis prescription, how this finding applies to a venous thromboembolism (VTE) or bleeding setting remains unknown, given that most studies are underpowered to assess these outcomes.[8]
We hypothesized that a multifaceted intervention for VTE guidelines implementation in emergency departments should improve prophylaxis use for patients hospitalized in medical wards and decrease the rate of VTE or major bleedings

Summary

Introduction

Prophylaxis appears to be used inappropriately and often underused for hospitalized medical patients.[6, 7] As system-wide standardized interventions may be more effective than relying on individual physicians’ routine practices, the American College of Chest Physicians has recommended “for every hospital, that a formal active strategy addressing the prevention of VTE be developed”.[5] A recent meta-analysis has suggested that alerts or multifaceted interventions increase prophylaxis prescription, how this finding applies to a VTE or bleeding setting remains unknown, given that most studies are underpowered to assess these outcomes.[8]. We hypothesized that a multifaceted intervention for VTE guidelines implementation in emergency departments should improve prophylaxis use for patients hospitalized in medical wards and decrease the rate of VTE or major bleedings. Misuse of thromboprophylaxis may increase preventable complications for hospitalized medical patients

Objectives

Methods

Results

Conclusion