Universal clinical decision support tool for thromboprophylaxis in hospitalized COVID-19 patients: post hoc analysis of the IMPROVE-DD cluster randomized trial

Abstract

BackgroundInpatient and extended postdischarge thromboprophylaxis of COVID-19 patients remains suboptimal despite antithrombotic guidelines. ObjectivesTo determine whether a novel electronic health record–agnostic clinical decision support (CDS) tool incorporating the International Medical Prevention Registry on Venous Thromboembolism plus D-dimer (IMPROVE-DD) venous thromboembolism (VTE) scores increases appropriate inpatient and extended postdischarge thromboprophylaxis and improves outcomes in COVID-19 inpatients. MethodsThis post hoc analysis of the IMPROVE-DD cluster randomized trial evaluated thromboprophylaxis CDS among COVID-19 inpatients at 4 New York hospitals between December 21, 2020, and January 21, 2022. Hospitals were randomized 1:1 to CDS (intervention, n = 2) vs no CDS (usual care, n = 2). The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included rates of major thromboembolism, all-cause and VTE-related readmissions and death, major bleeding (MB), and all-cause mortality 30 days after discharge. ResultsTwo thousand four hundred fifty-two COVID-19 inpatients were analyzed (CDS, 1355; no CDS, 1097). Mean age was 73.7 ± 9.37 years; 50.1% of participants were male. CDS adoption was 96.8% (intervention group). CDS was associated with increased appropriate at-discharge extended thromboprophylaxis (42.6% vs 28.8%; odds ratio [OR], 1.83; 95% CI, 1.39-2.41; P < .001). CDS was associated with reduced VTE (OR, 0.54; 95% CI, 0.39-0.75; P < .001), arterial thromboembolism (OR, 0.10; 95% CI, 0.01-0.81; P = .01), total thromboembolism (OR, 0.50; 95% CI, 0.36-0.69; P < .001), and 30-day all-cause readmission/death (OR, 0.78; 95% CI, 0.62-0.99; P = .04). There were no differences in MB, VTE-related readmissions/death, or all-cause mortality. ConclusionElectronic health record–agnostic CDS incorporating IMPROVE-DD VTE scores had high adoption, was associated with increased appropriate at-discharge extended thromboprophylaxis, and reduced thromboembolism and all-cause readmission/death without increasing MB in COVID-19 inpatients.