Venous thromboembolism reduction initiative:

Scott C. Woller, MD Co-Director Thrombosis Program

Intermountain Medical CenterProfessor of Medicine

University of Utah School of MedicineApril 6, 2017

A multifaceted collaborative effort to protect Intermountain Healthcare patients from hospital-

associated venous thromboembolism (HA-VTE)

14th Annual Research Summit

Disclosures

Investigator initiated grant recipient: Bristol-Myers-Squibb (paid to Intermountain Healthcare)

Grant support from Twine Clinical LLC (paid to Intermountain Healthcare)

Grant support from the Intermountain Research and Medical Foundation

Panelist American College of Chest Physicians (ACCP) Clinical Practice Guideline: Antithrombotic therapy for venous thromboembolic disease (AT10)

Objectives

The importance of thromboprophylaxis among hospitalized medical patients

Outcomes of VTE reduction initiative (VRI)

Discussion

Risk of Thrombosis

Hospitalization for acute medical illness increases the risk of VTE 8-fold1

• 2/3 of VTE events are attributable to hospitalization2

• 70-80% of fatal PE occur in nonsurgical patients2

Chemoprophylaxis decreases VTE among patients at risk3

Risk factors for VTE are well described

1. Heit JA Arch Int Med 2000;162. 2. Goldhaber SZ CHEST 2000; 118(6)3. Kahn et al. CHEST 2012; 141(2)(Suppl):e195S–e226S

Thromboprophylaxis recommendations

2.3. “For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with LMWH, LDUH B.I.D., LDUH T.I.D., or fondaparinux (1B)”

2.4. “For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (1B)”

VTE HIGH RISK for IMC 02/21/2010.07:00

SMITH, JOHN MMI: 1234567 Admit: 02/13/2010 RM: T345

Age: 89 CA: 3 Prior VTE: 3 Hyper: 0 Surg: 0 Bedrest: 0 Obese: 0

HRT/OCP: 0 VTE Risk Score: 7

Current Prophylaxis: NONE

Background: Intermountain VTE High Risk Alert

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Venous thromboembolism Reduction initiative

OBJECTIVES

Primary objective:Report the rate of appropriate chemoprophylaxis among hospitalized medical patients at high risk for VTE before and after the implementation of a multifaceted intervention including:• (a) targeted electronic alerts for high-risk patients

• (b) comparative practitioner metrics

• (c) practitioner-specific continuing medical education

Venous thromboembolism Reduction initiative

OBJECTIVES

Secondary objectives:• VTE

• Major bleeding

• Heparin-induced thrombocytopenia (HIT)

• Alert fatigue

• Physician satisfaction

Venous thromboembolism Reduction initiative

All hospitalists provided signed informed consent

Participation in the VRI and completion of all educational modules served as part of the 2011 hospitalist group incentive initiative

Hospitalist perceptions of the VRI were assessed in a standardized format at the time of initiation and at the end of the intervention year

IRB approval was granted by Intermountain Healthcare

Physician interface with personalized VTE RAM

Every morning at 0905 hours (rounding) a “just in time” text page was sent the hospitalist’ pager or cell phone if the patient met HA-VTE Risk criteria

Actionable EMR alert sent in conjunction with the text page

Physician interface with personalized VTE RAM

12

John Doe

John Doe

OR“REJECT” the VTE Risk Alert and select the rationale to turn off the text page alert for 5 days providing “credit” for appropriate prophylaxis

x

Individual Physician Feedback

The recommended educational activity is based on physician

performance data.

In this case, 12% of the instances of suboptimal prophylaxis (i.e. alerts

generated) were in cancer patients.

The recommendation for the track focused on thrombosis in cancer.

Physician-tailored continuing medical education

Physician-tailored continuing medical education

System Rate of VTE Prophylaxis

Summary of total patient days and patient encounters: overall, by risk group, and by year.

Patient encounter: a hospitalization

Patient day: a day the patient was in the hospital

Figure 1

Low Risk

2011

15,055 days

5,414 patient

encounters

2010

12,485 days

3,748 patient

encounters

2012

17,254 days

6,069 patient

encounters

High Risk63,717 days

20,186 patient encounters

44,794 days

15,195 patient encounters18,923 days

5,472 patient encounters481 patient encounters

overlap risk groups

2010

5,558 days

1,421 patient

encounters

2011

7,788 days

2,303 patient

encounters

2012

5,577 days

1,767 patient

encounters

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

RESULTS

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Primary Objective

The rate of appropriate chemoprophylaxis increased:

66.1% control period

81.0% intervention period

88.1% subsequent year

P <.001 for each comparison

Each dot represents the average monthly rate of appropriate chemoprophylaxis

Rate of appropriate chemoprophylaxis

among high risk patients

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

2010 2011 2012

Per

cen

tag

e o

f ap

pro

pri

ate

chem

op

rop

hyl

axis

APR JUL OCT JAN APR JUL OCT JAN APR JUL OCT JAN

Each bar represents the annual rate of appropriate chemoprophylaxis ordered by each hospitalist (A-X) for the years 2010, 2011, and 2012.

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Hospitalist

Pe

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nta

ge o

f A

pp

rop

riat

e C

he

mo

pro

ph

ylax

is

Overall Percentage of Appropriate Chemoprophylaxis by Hospitalist

Secondary Objectives

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Rate of venous thromboembolism, mortality, major bleeding, and heparin

induced thrombocytopenia among high-risk patients stratified by year(95% Confidence Interval) 2010 2011 2012 p-value

90 day VTE % 9.3 (7.8-10.9) 9.7 (8.5-11.0) 6.7 (5.6-8.0) 0.00930 day VTE % 7.3% (6.0-8.8) 7.9 (6.8-9.1) 4.9 (3.9-6.0) 0.00390 day all-cause mortality % 13.0 (11.2-14.9) 12.7 (11.3-14.1) 12.5 (10.9-14.1) 0.96In-hospital mortality % 2.4 (1.7-3.4) 2.1 (1.5-2.7) 1.6 (1.0-2.3) 0.43Thromboprophylaxis

Yes: in-hospital HIT* % 0.1 (0.0-0.5) 0.2 (0.0-0.5) 0.1 (0.0-0.4) 0.96Yes: Major bleeding* % 0.8 (0.4-1.6) 0.8 (0.5-1.3) 1.1 (0.6-1.7) 0.96No: Major bleeding* % 1.8 (0.6-4.1) 2.0 (0.9-3.9) 2.1 (0.8-4.6) 0.96

Secondary Objectives

Quarterly rates of behavioral change among

hospitalists during the intervention year

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

Eve

nt

Rat

eQ1 Q2 Q3 Q4

2011

Drop in alerts yet the rate of appropriate chemoprophylaxis increased.

Hospitalist response to the alerts increased over time, which refutes concern surrounding alert fatigue.

Suggestive that over time the hospitalists’ perceived increased value associated with the alerts.

CONCLUSIONS

Woller SC etal. The Am J Med (2016) 129, 1124.e17- 1124.e26

The VRI was associated with a significant increase in appropriate VTE prophylaxis

We observed a reduction in symptomatic HA-VTE

The VRI was well received by clinicians

SLIDE HEADING, CALIBRI 36 PT., ALL CAPS

Slide subhead, Calibri Body, 28 pt.• Key point number 1

• Key point number 2

• Key point number 3

o Supporting point number 3.1

o Supporting point number 3.2

https://www.cdc.gov/ncbddd/dvt/ha-vte-challenge.html

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THANK YOUIntermountain Research and Medical Foundation

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Intermountain Healthcare Hospitalist Group

Dr. Scott M. Stevens, MDDr. C. Greg Elliott, MDDr. R. Scott Evans, Ph.D.Dr. John Christensen, MDMatthew H. WayneDaniel G. WrayJim LloydValerie AstonEmily Wilson

QUESTIONS