# Presentation: 712190

## STRATEGIES TO IMPROVE THE USE OF VTE PROPHYLAXIS

- <date/time>

_**STRATEGIES TO IMPROVE THE USE OF VTE PROPHYLAXIS**_

- Samuel Z. Goldhaber, MD
- Cardiovascular Division
- Brigham and Women’s Hospital
- Professor of Medicine
- Harvard Medical School
- May 9, 2006

## CHANGING  MD  BEHAVIOR

- Guidelines alone do not suffice
- Strategies for change
- Surgeon General’s DVT Workshop
- Physician champions
- Registries
- Coalitions (Coalition to Prevent DVT)
- Litigation
**Electronic alerts**

## QUALITY IMPROVEMENT INITIATIVE TO IMPROVE CLINICAL PRACTICE

- Randomized controlled trial to issue or withhold electronic alerts to MDs whose high-risk patients were not receiving DVT prophylaxis

**(Kucher N et al. NEJM 2005; 352: 969)**

## COMPUTER  PROGRAM

- We developed a computer program linked to the patient database that screened the system daily to identify high-risk patients.
- We included consecutive high-risk patients on medical and surgical services who were not receiving DVT prophylaxis.

**(Kucher N et al. NEJM 2005; 352: 969)**

## DEFINITION:  “HIGH RISK”

**VTE risk score ≥ 4 points:**
- Cancer		3	(ICD codes)
- Prior VTE		3	(ICD codes)
- Hypercoagulability	3	(Leiden, ACLA)
- Major surgery		2	(> 60 minutes)
- Bed rest		1	(“bed rest” order)
- Advanced age		1	(> 70 years)
- Obesity		1	(BMI > 29 kg/m2)
- HRT/OC		1	(order entry)

## RANDOMIZATION

- <date/time>

_**RANDOMIZATION**_

**VTE risk score **_**>**_** 4**
**No prophylaxis**
**N = 2506**

**INTERVENTION**
**Single alert**
**n = 1255**

**CONTROL**
**No alert**
**n = 1251**

**(Kucher N, et al. NEJM 2005;352:969-977)**

## Slide 7

## BASELINE  CHARACTERISTICS

- Median age:		62.5 years
- Medical services:	83%
- Surgical services:	17%
- Comorbidities
- Cancer:			80%
- Hypertension:		34%
- Infection:			30%
- Prior VTE:		20%

**(Kucher N, et al. NEJM 2005; 352:969-977)**

## ORDERS:  DVT  PROPHYLAXIS

- 		_**Intervention**_**	**_**Control**_**	**_***P ***__**value**_
**	****	**_**n = 1255**_**	**_**n = 1251**_
**Overall**	 421 (33.5)	 182 (14.5)	< 0.001
**Mechanical**	 125 (10.0)	 19 (1.5)	< 0.001
-    GCS	 52 (4.1)	   7 (0.6)	< 0.001
-    IPC	 73 (5.8)	 12 (1.0) 	< 0.001
**Pharmacologic  **296 (23.6)	 163 (13.0)	< 0.001
-    Heparin	 213 (17.0)	 81 (6.5) 	< 0.001
-    Warfarin	 28 (2.2)	 41 (3.3)	  0.11
-    Enoxaparin	 55 (4.4)	 41 (3.3)	  0.18

**(Kucher N, et al. NEJM 2005;352:969-977)**

## PRIMARY END POINT:  90 DAYS

- 	_**Intervention**_**	**** **_**Control**_**	**_**Hazard ratio**_**	**_***P***_
- 	**(n = 1255)****	**** (n = 1251)****	****(95% CI)**
**Total VTE****	****61 (4.9)****	****103 (8.2)****	****0.59**** (0.43–0.81)****	****0.001**
**Acute PE****	****14 (1.1)****	****  35 (2.8)****	****0.40**** (0.21–0.74)****	****0.004**
**Prox.  DVT****	****10 (0.8)****	****  23 (1.8)****	****0.47 (0.20–1.09)****	****0.08**
**Distal DVT****	****  5 (0.4)****	****  12 (1.0)****	****0.42 (0.15–1.18)****	****0.10**
**UE DVT****	****32 (2.5)****	****  33 (2.6)****	****0.97 (0.60–1.58)****	****0.90**

**(Kucher N, et al. NEJM 2005;352:969-977)**

## PRIMARY  END  POINT

**Intervention**

**Control**

**N****umber**** at risk**

**1255**

**977**

**900**

**853**

**1251**

**976**

**893**

**839**

**(Kucher N, Koo S, Quiroz R, et al. NEJM 2005;352:969-977)**
**© 2005 Massachusetts Medical Society.  All rights reserved.)**

## RISK SCORE AND PROPHYLAXIS

- (Fanikos J et al.  ACC March 2006)

## VTE  PROPHYLAXIS:  THE  FUTURE

- Can a 3-screen alert improve physician response (34% in RCT and 40% in cohort)?
- Should we use an “opt in” vs. “opt out” strategy for alerts?
- Can human alerts function as well or better than electronic alerts?