Venous Thromboembolism Prophylaxis Rates Research Articles

Primary Thromboprophylaxis for the Prevention of Venous Thromboembolism in Cancer Patients with Central Venous Catheters: A Literature Review.

Cancer is a known risk factor for venous thromboembolism (VTE). The wider adoption of immunotherapy and anti-angiogenic drugs in recent years have increased this risk further. Central venous catheters (CVCs) are widely used access devices utilized to deliver infusion therapy, mostly in ambulatory settings. The endothelial injury associated with the use of these catheters adds to the risk of VTE to already high-risk patients. The introduction of direct oral anticoagulants (DOACs), with its proven efficacy and safety in multiple clinical indications, have renewed the attention to VTE prophylaxis in cancer patients with CVC. Several clinical trials and meta-analyses had shown that both apixaban and rivaroxaban are effective in lowering the risk of VTE, without increasing the risk of bleeding. Several risk assessment models (RAM) have utilized patient-related, tumor-related, and treatment-related factors, in addition to widely available biomarkers, like Hemoglobin (Hb) level, white blood cell (WBC) and platelets counts to stratify patients into two or three VTE risk levels. In this manuscript, we review the published clinical trials and meta-analyses that attempted to study the efficacy and safety of anticoagulants, mostly the DOACs, in cancer patients with CVCs. We will also propose a practical risk-directed approach to enhance VTE prophylaxis rate.

The effect of obligatory Padua prediction scoring in hospitalized medically ill patients: A retrospective cohort study.

Venous thromboembolism (VTE) is considered a preventable cause of mortality. The evidence for the benefit of VTE prophylaxis in acute medical patients is non-conclusive. Meta-analysis of RCTs failed to demonstrate reduction of all-cause mortality, while showing higher risk of bleeding. The Israeli Ministry of Health has instructed to assess all acute medical patients for the risk for VTE using the Padua Prediction Score, without mandating prophylaxis. To evaluate the effect of filling the Padua score on clinical outcomes and VTE prophylaxis rates. Retrospective Study was performed in Israel during the years 2014-2017. The participants were divided to Padua compliance vs non-compliance group. Primary outcome: 30-day mortality. Secondary outcomes: 90-day incidence of VTE and suspected major bleeding. A propensity-weighted logistic multiple regression was performed. 18,890 patients were included in the study. The fulfillment of the Padua score was associated with an increased use of VTE prophylaxis, OR 1.66 (95% CI 1.49-1.84). However, there was no reduction of mortality or VTE events, OR 1.13 (95% CI 0.97-1.31) and OR 1.22 (95% CI 0.79-1.8) respectively. Hospitalizations related to hemoglobin decrease were not statistically different between the two groups. Padua score for the assessment of VTE risk in medical wards was associated with higher administration of pharmacological prophylaxis without reduction in VTE or mortality rate. Its usage should be reassessed as a performance measure.

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center.

Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes. We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk. Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%. Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

Risk of venous thromboembolism and appropriateness of thromboprophylaxis in patients undergoing lower limb orthopedic surgery in a Vietnamese hospital

Patients undergoing orthopedic surgery are at high risk of venous thromboembolism (VTE), but the prophylactic practices are suboptimal. We aim to investigate the risk of VTE, the appropriateness of VTE prophylaxis and its associated factors in patients undergoing lower limb orthopedic surgery. A cross-sectional study was conducted at Gia Dinh People’s Hospital. Data was collected from medical records of patients aged ≥18 years undergoing lower limb orthopedic surgery between March 1st 2020 and June 30th 2020. VTE risk was stratified using the Caprini Risk Assessment Model, contraindications to anticoagulation and the appropriateness of thromboprophylaxis were evaluated according to current guidelines. Multivariate logistic regression analysis was used to determine factors associated with the appropriateness of VTE prophylaxis. A total of 217 patients was included (median age 54, 57.6% male). There were 80.2% of patients at risk of VTE. Overall rate of appropriate VTE prophylaxis was 35.0%. Patients with age ≥41, BMI >25 kg/m2, surgical duration >45 minutes, plaster cast or screw splint were less likely to receive appropriate VTE prophylaxis; patients with hospital stay >4 days after surgery got more chances to have proper VTE prophylaxis (p <0.05). The majority of patients undergoing lower limb orthopedic surgery were at risk of VTE, but the rate of appropriate VTE prophylaxis was low. Factors associated with the appropriateness of VTE prophylaxis were age, BMI, surgical duration, plaster cast or screw splint, and length of hospital stay after surgery. Interventions are needed to improve the appropriateness of VTE prophylaxis.

A215 EVALUATING THE COMPARABILITY OF CARE FOR PERSONS ADMITTED TO TORONTO AREA HOSPITALS WITH ACUTE SEVERE ULCERATIVE COLITIS

Abstract Background Approximately 20% of patients with ulcerative colitis will experience an acute severe exacerbation requiring hospitalization. Acute severe ulcerative colitis (ASUC) is a medical emergency associated with significant morbidity and a mortality rate of 1%. Timely initiation of treatment and assessment of clinical response is critical in the management of ASUC. With an aim to reduce treatment variability and improve outcomes, multiple gastrointestinal societies have published guidelines highlighting recommendations for optimal care in ASUC. It remains unclear how closely these guidelines are implemented in clinical practice. Measuring adherence to these recommended processes of care may act as a surrogate measure for quality of care and a way to indirectly evaluate outcomes in the management of patients with ASUC. Studies have shown that even amongst experienced providers practice pattern variability exists. Identifying significant variations in the management of patients with ASUC will highlight where improvement in guideline dissemination and greater adherence is required. Purpose We sought to evaluate how quality of care indicators varied across 7 hospital sites for patients admitted ASUC in the Greater Toronto Area. Method Using GEMINI, a research collaborative that collects and analyses data from inpatient admissions at 7 Toronto area hospitals, we identified patients admitted to hospital with ASUC from June 2016-December 2019. Hospital sites were further categorized into 3 hospital types; 1 IBD specialty centre (ISC), 3 other academic centres (AC) and 3 community centres (CC). Process measures assessed included proportion tested for C-reactive protein at baseline and following treatment initiation, duration of corticosteroid use, timing and initiation of biologic agents, rates of venous thromboembolism prophylaxis and opioid use. Outcome measures included hospital length of stay, rates of colectomy and mortality. Result(s) 765 hospitalizations were included in the study; 320 occurring at ISC, 308 at AC and 137 at CC. Corticosteroid use on admission were highest at the ISC at 78% compared to 64% at AC and 63% at CC (p <0.001). Among those who received steroids on admission, 47% of patients remained on intravenous corticosteroids for at least 5 days in the ISC compared to 39% in AC and 75% in CC (p< 0.001). Initiation of biologic rescue therapy was highest at the ISC occurring in 37% of hospitalizations compared to 22% in AC and 23% in CC (p<0.001). In addition, VTE prophylaxis rates were highest at the ISC at 83% followed by 60% in AC and 45% in CC (p<0.001). Rates of colectomy were highest at ISC (12% of hospitalizations vs. 7% in AC). Conclusion(s) Greater adherence to indicators of quality of care were seen at the ISC compared to ACs and CCs, although patient outcomes assessed were not clearly different between sites. Further strategies are required to improve adherence to markers of quality care for patients admitted with ASUC. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Venous Thromboembolism Prophylaxis in Pediatric Inflammatory Bowel Disease Patients Hospitalized With a Central Line.

Patients hospitalized with inflammatory bowel disease (IBD) have increased risk of venous thromboembolism (VTE). The aim of this study was to determine whether the adoption of a VTE protocol would change rates of medical VTE prophylaxis (low molecular weight heparin) in patients with IBD and a central venous catheter (CVC), while subsequently decreasing the incidence of VTE in this population. A protocol for VTE prophylaxis in IBD was established in March of 2018. Every patient hospitalized with an IBD flare and central venous access from March 2013 to March 2020 was identified. Study data, including patient demographics, rates of Doppler ultrasound (US), and rates of VTE were collected using International Classification of Diseases (ICD)-10 codes, CPT codes, and chart review retrospectively. Determination of an IBD flare was based on physician global assessment. Groups were compared with independent-sample t tests and chi-squared tests. A total of 313 hospitalizations across 187 different patients were identified that met criteria including IBD and central venous access. VTE prophylaxis increased from 5.24% (n = 12) prior to the intervention to 63.10% (n = 53) after the intervention [chi-square (1, N = 313) = 125.0192, P < 0.001]. Rate of Doppler US increased from 9.17% (n = 21) prior to the intervention to 17.86% (n = 15) after the intervention [chi-square (1, N = 313) = 4.5562, P < 0.05]. Diagnosis of VTE increased from 0.87% (n = 2) prior to the intervention to 7.14% (n = 6) after the intervention [chi-square (1, N = 313) = 9.6992, P < 0.01]. There were no significant differences in the demographic characteristics pre- versus post-intervention. Rates of Doppler US and VTE prophylaxis use increased significantly after implementation of a VTE protocol. Rates of VTE diagnosis also increased, though we suspect this may be due to missed diagnoses prior to implementation of the protocol and increased risk awareness after the protocol was established.

Survey of U.S. Healthcare Providers to Assess Attitudes and Practices Regarding Thromboprophylaxis of Hospitalized Adult Patients

Background: Venous thromboembolism (VTE) is a leading cause of mortality among hospitalized patients, but appropriate thromboprophylaxis remains underutilized. A significant proportion of VTE associated with hospitalization occurs after discharge. We conducted a national survey of healthcare providers to explore attitudes, practices, and barriers related to thromboprophylaxis in hospitalized patients, including practices for post discharge VTE prevention. Methods: We developed a survey exploring current attitudes and practices around VTE prophylaxis in adult hospitalized patients. Healthcare providers targeted for the survey were physicians, nurses, physician assistants, and pharmacists. The survey was administered to a targeted convenience sample. Participants were recruited through social media, professional healthcare organizations, and internal medicine program directors across the US. The overarching survey areas included (1) use of appropriate prophylaxis, including perceived rates of appropriate prophylaxis at respective institutions, (2) perceived barriers to appropriate prophylaxis, (3) practices to educate about and prevent post discharge VTE events, and (4) views on use of risk assessment models (RAMs) and other strategies to improve rates of VTE prophylaxis. Since it is generally understood by the healthcare provider respondents of this survey that administration of VTE prophylaxis depends on a patient's risk, survey questions did not specify a definition for appropriate prophylaxis. We summarized data as proportions with 95% confidence intervals (CI). Results: Of 607 U.S.-based respondents, 69.9% were 40 years or younger, 55.7% were female, 68.2% were white, and 63.1% reported working in an academic hospital. Physicians comprised 70.7% of respondents, of whom 46.6% identified as trainees; among non-trainees, 49.0% had been in practice for more than 10 years. Hospital medicine was the most frequent specialty (52.1%) followed by hematology (20.8%). Nearly all respondents agreed that VTE prophylaxis is important for patient care (98.8%, 95% CI: 97.6-99.5) and that current measures are safe (92.6%, 95% CI: 90.2-94.5) and effective (93.8%, 95% CI: 91.6-95.6). Yet only 52.0% (95% CI: 47.9-56.0) of respondents perceived that hospitalized patients at their institution were on appropriate VTE prophylaxis almost all of the time. The most commonly cited reasons for patients not being on appropriate VTE prophylaxis included patient refusal (21.8%), risk of bleeding outweighs benefit (21.6%), and unclear indications (16.0%) and contraindications (17.6%) for prophylaxis. Less than half of respondents reported using institutional protocols (48.3%) or a standardized RAM (35.4%) to select patients for VTE prophylaxis and most respondents (72.3%) relied on clinical judgement to assess bleeding risk when deciding on prophylaxis (Figure 1). Respondent views on strategies that could improve VTE prophylaxis rates in hospitalized patients included integration of RAMs into electronic health records (66.6%), automatic electronic reminders (55.0%), and order sets in electronic systems (46.1%) (Figure 2). Less than 20% of respondents reported routinely educating patients about risks (15.1%, 95% CI: 12.3-18.2) and symptoms (17.9%, 95% CI: 14.9-21.2) of post-discharge VTE events, and 8.6% (95% CI: 0.06-11.1) routinely prescribe VTE prophylaxis on discharge. Respondent views on strategies that could help reduce post-discharge VTE events included using standardized risk assessments at discharge (60.0%), providing educational materials at discharge (51.2%), and including post-discharge VTE prophylaxis in discharge checklists (45.5%) (Figure 2). Conclusion: To our knowledge, this is the largest U.S. national survey to date that focuses on VTE prevention practices in hospitalized patients. VTE prophylaxis was almost universally accepted as important, safe, and effective for patients at risk for VTE. Less than half of the respondents reported using standardized protocols or RAMs to guide appropriate thromboprophylaxis administration. Discharge education regarding risks of VTE is infrequent. This national multidisciplinary survey study highlights gaps in current practices and strategies for VTE prevention in hospitalized patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

S912 Prevention of Venous Thromboembolism in IBD Patients May Not Be Associated With Prophylaxis Rates

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) -

Venous thromboembolism risk assessment and prophylaxis in hospitalised medical patients in the Cape Town metropole, South Africa

Background. Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians’ perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident. Objectives. To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA). Methods. A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated. Results. Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for &lt;72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients. Conclusions. Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Risk Assessing Medical Inpatients for Hospital-Acquired Venous Thrombosis: The Medical Inpatients Thrombosis and Hemostasis (MITH) Study

Introduction: Multiple regulatory agencies and professional societies recommend risk assessment of hospitalized medical patients for hospital-acquired (HA) venous thromboembolism (VTE) and provision of pharmacologic prophylaxis to those at risk. Extant risk assessment models (RAMs) include risk factors not knowable or difficult to assess at admission and often do not include risk factors reflecting illness acuity (such as laboratory studies and vital signs at admission). We developed a RAM for HA-VTE that reports absolute VTE risk, as opposed to arbitrary risk categories, using only objective risk factors measured within the first 24 hours of admission.Methods: The study setting was a combined academic and community 540-bed teaching hospital in northwest Vermont (The University of Vermont Medical Center). Using validated electronic health record (EHR) derived phenotypes (computable phenotypes), we captured all medical admissions between 2010-2019 and examined patient demographics, past medical history, and presenting vital and laboratory measures as potential risk factors for HA-VTE. As risk assessment should happen within 24 hours of admission, we only assessed risk factors knowable within this timeframe. Individuals with VTE at admission were excluded. Key outcome and risk factor definitions were validated using chart review. Bayesian logistic regression with a least absolute shrinkage and selection operator (LASSO) prior probability distribution was used to select risk factors for the model. Variables with a t-statistic ≥1.5 or ≤-1.5 were included in the final model. Full or prophylactic anticoagulation use was adjusted for in the final model. Model performance was assessed using bootstrap resampling to estimate area under the receiver operating characteristic (AUC) curve and calibration slope with 95% confidence interval (CI).Results: There were 62,468 medical admissions in the study period with 219 HA-VTE events. Chart review demonstrated the positive predictive value of our HA-VTE computable phenotype to be 84% and the negative predictive value 99%. Mean age was 65 years and 51% were male. Comorbid conditions were common in this hospitalized population, including active cancer (29%), congestive heart failure (25%), diabetes (27%), hypertension (59%), and prior myocardial infarction (13%). Seven risk factors met the criteria for inclusion in the final model: prior history of VTE (OR 2.7; 95% CI 1.8, 3.8), red cell distribution width ≥14.7% (OR 1.6; 95% CI 1.2, 2.2), creatinine ≥2.0 mg/dL or on dialysis (OR 2.0; 95% CI 1.4, 2.8), serum sodium <136 MEq/L (OR 1.5; 95% CI 1.1, 2.1), active cancer (OR 1.4; 95% CI 1.1, 2.0), malnutrition based on prior reported weight loss (OR 2.1; 95% CI 1.3, 3.3), and low hemoglobin (<13.6 g/dL in men, <12.1 g/dL in women; OR 1.5; 95% CI 1.0, 2.1). The unadjusted AUC of the RAM was 0.73 with an unadjusted calibration slope 1.09 (Figure 1). The optimism-adjusted AUC was 0.68 (95% CI 0.64, 0.71) and the optimism-adjusted calibration slope was 0.87 (95% CI: 0.72, 1.03).Discussion: We developed and internally validated a RAM for HA-VTE during medical hospitalization which incorporates simple, objective risk factors knowable within the first 24 hours of admission. Unlike most prior RAMs, this model also incorporates risk factors reflecting illness severity such as laboratory results. The RAM has good fit and calibration and will be moved forward to external validation. Future applications include incorporating the RAM into hospital admission workflows and assessing VTE prophylaxis rates and the incidence of HA-VTE and HA-bleeding. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTE-PACC): a Systems-Based, Personalized, Multidisciplinary Program to Increase Venous Thromboembolism (VTE) Risk Assessment, Education and Anticoagulant Prophylaxis in Cancer Outpatients Initiating Therapy

Introduction : Anticoagulant prophylaxis reduces VTE rates by ~50% in selected oncology patients. Among cancer patients starting chemotherapy, 2014 ASCO Guidelines recommend VTE risk assessment, VTE education, and administration of pharmacologic prophylaxis in selected patients. While validated VTE risk stratification tools are available, <10% of oncologists use a risk assessment tool in practice. Further, evidence-based and practical guidance for how to implement VTE prevention guidelines in cancer outpatients is lacking.Hypothesis : Implementation of a systems-based multidisciplinary program that utilizes the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations by consulting hematologists would increase VTE risk assessment, increase VTE education rates, and increase the rate of VTE prophylaxis in high risk patients initiating outpatient chemotherapy.Methods: At a tertiary university cancer center, based on a quality improvement framework with an iterative design to refine the intervention over time, VTE-PACC is a multidisciplinary thrombo-oncology program developed and implemented by nurses, oncologists, pharmacists and hematologists. We identified high risk patients, provided standardized VTE education, and tailored prophylaxis for adult cancer outpatients initiating chemotherapy. Patients receiving hormonal therapy or with brain cancer were not included in the program. An assessment of VTE risk using the Khorana and Protecht scores via the EHR was built into clinical process flow and all patients were provided education on VTE symptoms and risk reduction. Patients with a high predicted VTE risk during treatment (defined as ≥3 points on the Khorana or Protecht score) were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation including individualized drug and dosing recommendations were communicated to the treating oncologist.Results : Between October 1, 2015 and July 1, 2017 (comprising a 6 month implementation phase and subsequent 15 months post implementation), 850 patients were evaluated. VTE risk assessment and education rates increased from less than 5% to 84.3% (range 65.8- 97.6% per month) during the implementation phase. Improvement in EHR documentation processes and clinical work flow resulted in a further increase to 94.9% over the subsequent 15 months. In the post-implementation phase, 153 patients (23.7%) were identified as high risk of VTE based on the Khorana or Protecht scores and offered referral to hematology. The largest patient derived factor for referral acceptance was consultative visits coincident with receiving therapy or an oncology visit. Of these high risk patients, 86% received prophylactic anticoagulation therapy (49% DOAC (direct oral anticoagulant), 32% low molecular weight heparin, 17% unfractionated heparin and 2% warfarin).Conclusion: The VTE-PACC intervention used a multidisciplinary EHR based approach to improve VTE risk assessment and education rates in cancer outpatients initiating therapy. The great majority of high risk patients also received prophylactic anticoagulation. As large trials on the benefits and risks of pharmacologic prophylaxis are completed, methods applied here may readily translate these findings into practice. DisclosuresNo relevant conflicts of interest to declare.

Improving rates of venous thromboembolism prophylaxis in multiple myeloma patients on immunomodulatory drugs through a pharmacy-based system.

Immunomodulatory drugs used to treat multiple myeloma carry an increased risk of venous thromboembolic (VTE) disease. Previously published guidelines outline consensus opinion on how to mitigate this risk. We collected baseline data to analyze how these strategies are utilized at our single institution and sought to improve the rates of anticoagulation for high-risk patients. This was done through a quality improvement project that added pharmacy/haematology oversight to the VTE risk assessment. Thirty-nine patients newly started on IMiDs were assessed for VTE risk. This information was passed on to the myeloma provider for consideration. Twenty-two patients were classified as high risk for VTE. Of the high-risk patients, 14 (64%) were placed on an anticoagulant for thromboprophylaxis. Eleven (79%) of the 14 used direct oral anticoagulants (DOACs). Eight high-risk patients did not receive an anticoagulant for thromboprophylaxis; 4 of these developed VTE. No patients on anticoagulation developed a VTE. This strategy had rare minor bleeding complications. This quality action verifies guideline-based thromboprophylaxis in multiple myeloma and supports the benefit of pharmacy oversight in improving VTE rates. The use of DOACs in myeloma should be further explored.

A cross-sectional, multicenter, observational study to assess the prophylaxis of venous thromboembolism in Lebanese and Jordanian hospitals

BackgroundThere is a growing body of evidence showing substantial underuse of appropriate venous thromboembolism (VTE) prophylaxis in patients at risk. In the present study, our goal was to assess the current practices in the use rate of VTE prophylaxis among hospitalized patients in Jordan and Lebanon.MethodsA cross-sectional, multicenter, observational study was conducted on 40 centers across Lebanon and Jordan. We included patients who were admitted to the participating hospitals for the treatment of a serious medical or surgical illness. The patients’ records were screened for the fulfillment of inclusion/exclusion criteria during a single assessment visit. The proportion of medical and surgical patients who were at risk of VTE and the thrombo-prophylactic measures employed by physicians for these patients were assessed according to the American College of Chest Physicians (ACCP 2016) guidelines.ResultsThe present study included 704 patients (400 from Jordan and 304 from Lebanon) with a mean age of 54.9 ± 17.5 years. Almost 59% of the patients received prophylaxis treatment in form of pharmacological anticoagulant prophylaxis and/or mechanical prophylaxis. Low molecular weight heparin was the most commonly used anticoagulant for VTE prophylaxis in 366 out of the total 704 (51.9%) patients in the analysis cohort. Two hundred and sixteen patients (52, 95% confidence interval [47.1–56.9%]) received appropriate prophylactic agents out of 415 patients who were eligible for prophylaxis according to the ACCP 2016 guidelines. On the other hand, 199 (72.1, 95% confidence interval [66.4–77.3%) patients received prophylaxis out of 276 ineligible patients. The rate of compliance to guidelines showed wide variations according to the type of hospital, specialty, and the patients’ age. The multivariate logistic regression analysis showed that only age was a significant predictor of appropriate VTE prophylaxis (odds ratio [OR] 1.05, P < 0.001).ConclusionThe rates of the appropriate use of VTE prophylaxis are low in Lebanon and Jordan. There is a lack of compliance to guidelines for VTE prophylaxis use for hospitalized patients in both countries.

Do Inpatients Receive Risk-Based Prophylactic Treatment for Thrombotic Events?

Background:Current guidelines recommend risk-based use of prophylaxis for preventing medical inpatients from venous thromboembolism (VTE). Little is known about the current prescription practice, and even less whether differences between subspecialists like cardiologists, usually treating patients with thrombotic or thromboembolic diseases, and gastroenterologists, treating more patients with gastrointestinal bleeding complications, exist.Methods:We performed a retrospective chart review of patients on cardiology and gastroenterology wards of our university hospital. Patients with a clear indication for anticoagulation and contraindication against antithrombotic treatment were excluded. A total of 450 patients per specialty were included. Quantitative risk assessment models were used to determine the risk of a VTE (Padua Prediction Score (PPS), IMPROVE Score) and bleeding (IMPROVE-Bleeding and HAS-BLED Score).Results:The overall rate of VTE prophylaxis was high in both patient populations. Significant more low-risk cardiology compared to gastroenterology patients received drug-based prophylaxis. Furthermore, crucial discrepancies were found in the way individual patients would be classified based on PPS and IMPROVE Score. Finally, not the risk category but the length of hospital stay was best at predicting which patient received prophylaxis.

The effect of physician educational intervention on venous thromboembolism pharmacological prophylaxis in medical inpatients from the respiratory department: a retrospective cohort study.

Venous thromboembolism (VTE) is a serious health problem for which pharmacological prophylaxis has been proven to be effective. However, there are significant gaps between the guidelines and clinical practice. This study is to evaluate the effect of physician educational intervention (PEI) on VTE pharmacological prophylaxis in medical inpatients from the respiratory department. Medical inpatients from the respiratory department between February 2014 and December 2016 were recruited in this retrospective cohort study. They were assigned to the PEI group or the control group according to whether their physicians undertook a quality improvement (QI) project carried out in hospital to raise physician awareness of pharmacological thromboprophylaxis by educational intervention. Any and appropriate pharmacological VTE prophylaxis rates, the use of appropriate anticoagulants, and the occurrence of VTE events in the two groups were calculated and compared using a chi-square test and continuity correction. Poisson regression analysis was used to evaluate the relative risk (RR) of PEI on the occurrence of VTE events. The any pharmacological VTE prophylaxis rate (11.3% vs. 5.9%, P=0.048) and appropriate pharmacological VTE prophylaxis rate (9.3% vs. 5.5%, P=0.036) in high-risk patients without high major bleeding risk were both significantly higher than the control group. Compared with the control group, appropriate anticoagulants in the PEI group took up a larger proportion of all used anticoagulants (90.3% vs. 78.7%, P=0.007). In anticoagulants used for high-risk patients without high major bleeding, appropriate anticoagulants show no statistical difference between the two groups (93.8% vs. 77.8%, P=0.153). There was no difference in the occurrence of VTE events between the two study groups in overall patients (0.5% vs. 0.6%, P=0.913), and among those with high VTE risk (1.7% vs. 1.0%, P=0.554). PEI had no association with the probability of VTE event occurrence (RR, 1.246; 95% CI, 0.478-2.188, P=0.954). Educational intervention effectively increased physician awareness of VTE prophylaxis in the respiratory department. Further interventions are still necessary since the guidelines were implemented to a relatively low degree.

Improving venous thromboembolism prophylaxis through critical thinking and health informatics.

Venous thromboembolism (VTE) is a leading cause of preventable morbidity and mortality in hospitalised patients. Mafraq Hospital, a 450-bed tertiary-level hospital in Abu Dhabi, United Arab Emirates, has identified VTE prevention as a critical patient safety measure and VTE prophylaxis as a key performance indicator (KPI). Mafraq Hospital VTE prevention policy states that all admitted adult patients 18 years and above should receive a VTE risk assessment, and all patients identified at risk of VTE with no contraindications should receive appropriate VTE prophylaxis within 24 hours of admission. In a move towards safer practices, our governing body, Abu Dhabi Health Services SEHA, has raised the VTE prophylaxis KPI target from 85% to 95% for all admitted adult patients within 24 hours of admission. Our average VTE prophylaxis rate was 87%, and achieving this new target was a challenge. We conducted this study on Mafraq Hospital Medical and Surgical wards. The study period was 12 months, from July 2018 to June 2019, and a total of 5475 patients were evaluated. Our aim was to improve VTE prophylaxis rates in order to ensure patient safety and reduce preventable harm. We used Caprini Model electronic VTE risk assessment computerised decision support tool to help identify VTE risk. A multidisciplinary task force team was formed and led this quality improvement project. The purpose of this publication was to indicate the quality improvement interventions implemented to enhance compliance with VTE prophylaxis using integrated critical thinking and health informatics and the outcomes of those interventions. Through implementing critical thinking and health informatics interventions, our VTE prophylaxis within 24 hours of admission rates improved from an average 87% in July 2018 to above 98%, and this improvement was sustained over the last 3 months of the study period April through June 2019.

Rates of primary prophylaxis for venous thromboembolism in high-risk patients with pancreatic and gastric cancer: A single tertiary care academic center experience.

e19274 Background: Venous thromboembolism (VTE) causes significant morbidity and mortality in patients with cancer. The International Society of Thrombosis and Hemostasis published guidelines in 2014 recommending a risk-based approach to VTE prophylaxis in ambulatory cancer patients, but uptake in real-world clinical practice is unknown. This study's objective was to describe rates of primary VTE prophylaxis in ambulatory patients with gastric and pancreatic cancer receiving chemotherapy and at increased risk of VTE. Methods: We identified patients at a single academic tertiary care center who received chemotherapy from 1/1/2015 to 10/1/2018 for a diagnosis of pancreatic or gastric cancer through retrospective query of electronic health records. Data abstracted included the Khorana score components (body mass index, leukocyte, hemoglobin, and platelet counts) on day of chemotherapy initiation, anticoagulation prescription, and VTE diagnosis within 6 months of chemotherapy initiation. Patients were excluded if they had contraindications to anticoagulation or alternate indications for anticoagulation. Results: We identified 437 patients, of which 72% had pancreatic cancer and 29% had gastric cancer. Mean (standard deviation) age was 64.2 (11.7) years, and patients were predominately male (54%) and white (75%). Overall, only 13% of patients received a prescription for anticoagulation with similar rates in patients with pancreatic cancer (14%) compared to gastric cancer (9%). Anticoagulation prescription rates by Khorana score (2 or ≥3) are shown in Table. Approximately 10% of patients had a VTE within 6 months of chemotherapy initiation. Conclusions: Our results show that in a cohort of patients with gastric and pancreatic cancer at intermediate to high-risk of VTE by Khorana score (≥2), only 1 in 10 received a prescription for prophylactic anticoagulation. In addition, we observed high rates of incident VTE in 6-month follow-up confirming the high-risk nature of this group. Opportunity remains to enhance implementation of primary VTE prevention in clinical practice to reduce VTE morbidity and mortality in patients with cancer. [Table: see text]

Successful Model for Guideline Implementation to Prevent Cancer-Associated Thrombosis: Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic.

PURPOSE:Guidelines recommend venous thromboembolism (VTE) risk assessment in outpatients with cancer and pharmacologic thromboprophylaxis in selected patients at high risk for VTE. Although validated risk stratification tools are available, < 10% of oncologists use a risk assessment tool, and rates of VTE prophylaxis in high-risk patients are low in practice. We hypothesized that implementation of a systems-based program that uses the electronic health record (EHR) and offers personalized VTE prophylaxis recommendations would increase VTE risk assessment rates in patients initiating outpatient chemotherapy.PATIENTS AND METHODS:Venous Thromboembolism Prevention in the Ambulatory Cancer Clinic (VTEPACC) was a multidisciplinary program implemented by nurses, oncologists, pharmacists, hematologists, advanced practice providers, and quality partners. We prospectively identified high-risk patients using the Khorana and Protecht scores (≥ 3 points) via an EHR-based risk assessment tool. Patients with a predicted high risk of VTE during treatment were offered a hematology consultation to consider VTE prophylaxis. Results of the consultation were communicated to the treating oncologist, and clinical outcomes were tracked.RESULTS:A total of 918 outpatients with cancer initiating cancer-directed therapy were evaluated. VTE monthly education rates increased from < 5% before VTEPACC to 81.6% (standard deviation [SD], 11.9; range, 63.6%-97.7%) during the implementation phase and 94.7% (SD, 4.9; range, 82.1%-100%) for the full 2-year postimplementation phase. In the postimplementation phase, 213 patients (23.2%) were identified as being at high risk for developing a VTE. Referrals to hematology were offered to 151 patients (71%), with 141 patients (93%) being assessed and 93.8% receiving VTE prophylaxis.CONCLUSION:VTEPACC is a successful model for guideline implementation to provide VTE risk assessment and prophylaxis to prevent cancer-associated thrombosis in outpatients. Methods applied can readily translate into practice and overcome the current implementation gaps between guidelines and clinical practice.

Minor Hematochezia Decreases Use of Venous Thromboembolism Prophylaxis in Patients with Inflammatory Bowel Disease.

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.

654 Improving Inflammatory Bowel Disease Care: A Quality Improvement Project for Venous Thromboembolism Prophylaxis

INTRODUCTION: Inflammatory Bowel Disease (IBD) patients admitted with a flare are 5-6x more likely to have a complication with venous thromboembolism (VTE). As a result, more emphasis is being placed on administering chemical prophylaxis to these patients. A 6-month retrospective chart review of patients hospitalized at our institution with an IBD flare without severe GI bleeding revealed that only 39% received chemical VTE prophylaxis. Herein, we designed a quality improvement project with an aim to improve this rate to over 75%. METHODS: Our initial Ishikawa diagram was used to map out the entire process from which a patient enters the emergency room until they are admitted to their hospital bed to analyze reasons DVT chemoprophylaxis was withheld. “Bleeding” was the most commonly documented reason. We then decided to target the patient population to hospitalized IBD flares without severe GI bleeding. The parameters we set for this included Hemoglobin &lt;7 g/dL, tachycardia, and/or hypotension. Our main intervention was placing reminder sheets in each Internal Medicine team room with the aforementioned parameters for appropriate use of chemical prophylaxis. Further, a department-wide e-mail was sent to all of Internal Medicine with the reminder sheet attached and educational text. RESULTS: Over the 4 months post-intervention, VTE prophylaxis rates for hospitalized IBD flares without severe bleeding (n = 14) improved to 100%. Hospitalization related costs for a diagnosis of “DVT” or “PE” are reportedly ∼$10,000 &amp; $20,000, respectively. The cost of Lovenox for a 5 day length of stay for an 80 kg man is $420. There is an estimated 7.6 to 41% risk of VTE amongst patients hospitalized for flares. At University Hospital, we averaged about 4 flares without severe bleeding/month. Using 25% risk for 48 patients per year, this could potentially lead to 12 VTE prevented/year. Taking all of this into account there is a potential 900% return on investment with savings of about $160,000/year. CONCLUSION: It does appear that our interventions helped us reach our goal to improve VTE prophylaxis rates in IBD flares. A weakness, however, is the low sample size of patients, but we do plan to continue collecting data over the next year. Further, education has been proven to be a weak intervention with poor sustainability in the world of QI. The main plan for sustainability remains to work with IT to implement “IBD flare without severe bleeding” as a check-mark for high-risk of VTE on the admission order set.