Developing the Form and Content of Implementation Strategies to Prevent Venous Thromboembolism for Ambulatory Patients with Cancer
Authors: Martin Karlyn A. , Cameron Kenzie A , O'Brien Matthew , Linder Jeffrey A , Hirschhorn Lisa 
Published: December 2023

Introduction
To prevent venous thromboembolism (VTE) in people with cancer, guidelines recommend risk-assessment for those receiving systemic therapy and anticoagulation (AC) prophylaxis for those at high risk of VTE. However, these recommendations are significantly underused in clinical practice. Our prior work demonstrated barriers and facilitators contributing to this underuse and identified potential implementation strategies to address these barriers. The objective of this study was to develop the form and content of targeted implementation strategies promoting the uptake in clinical practice of guideline-recommendations for VTE prevention for ambulatory patients with cancer.
Methods
We conducted multidisciplinary stakeholder focus group discussions and semi-structured patient interviews to iteratively design the form and content of five implementation strategies (Table 1): (1) Conduct clinician education and training on risk-assessment models and anticoagulation thromboprophylaxis; (2) Adapt electronic health records (EHR) to provide interactive assistance; (3) Develop and distribute educational materials for clinicians about the Khorana score, VTE risk, and AC counseling; (4) Develop and distribute educational materials for patients; and (5) Audit and feedback. Stakeholders included oncologists, classical hematologists, an oncology clinical pharmacist, oncology advanced practice providers, and oncology patients, in academic and community-based settings within a single health care system. We conducted the clinician focus groups iteratively: in the first session we reviewed guidelines and evidence to support the use of risk assessment and AC prophylaxis in patients with cancer and shared barriers and facilitators identified in our earlier work. During subsequent sessions, we iteratively designed the form and content of the implementation strategies. In the final session, clinicians were presented a finalized prototype of the implementation strategies and asked to perform exploratory usability testing through simulated patient care encounters. Individual semi-structured interviews were conducted with patients to obtain feedback on the design of the implementation strategies and patient-education resources.
Results
A workflow for integration of risk-assessment and relevant prophylaxis in clinical practice was created based on participant feedback. Details for selected implementation strategies are shown in Table 1. For EHR support, stakeholders recommended the risk-assessment component be integrated within chemotherapy order sets. In addition, they recommended incorporating aid for AC management within the EHR, including a method to assess bleeding risk, pre-populated options for AC thromboprophylaxis, provision of easily accessible links to resources for peri-operative/procedure AC management, and a list of interactions between anticoagulants and common drugs used in oncology practice. Clinician stakeholders also recommended - and subsequently approved - standard phrases available to incorporate into the EHR documentation, both to guide decision-making and to serve as a reminder to re-assess in future visits. For education resources (clinician and patient), clinicians wanted education resources to be concise, and for the patient-facing resource, to be provided to patients both in existing “chemotherapy education” booklets and sent in after-visit appointment instructions. Regarding audit and feedback, clinicians recommended a personalized report card comparing their use of appropriate VTE prevention to their peers. After reviewing the patient-facing education documents, patients recommended simpler, straightforward language and clarifications for the VTE and AC patient education resources based on their past experiences.
Conclusions
With multidisciplinary stakeholder input from clinicians and patients, we developed a set of implementation strategies designed to address barriers to uptake of VTE prevention recommendations in oncology clinics. Next steps are to test the implementation strategies in clinical practice to measure impact on increasing these evidence-based interventions.