New York Medical College and Montefiore Medical Center North, Bronx, NY, USA.
J Am Med Dir Assoc. 2012 Mar;13(3):303-7. doi: 10.1016/j.jamda.2011.04.015. Epub 2011 May 31.
Implementation of prophylaxis for venous thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) is variably adopted in long term care facilities (LTCF). Current guidelines recommend venous thromboembolism prophylaxis (VTE-P) following risk assessment, individualized to patient status. In LTCF, differing comorbidity, life-expectancy, ethical, and quality-of-life issues may warrant a unique approach. This article examines VTE-P practices in LTCF before and after educational intervention to bring practice patterns consistent with CPGs.
Phase 1 (preceding article in this issue) identified current practice to assess risk and implement VTE-P (17 geographically diverse LTCFs, 3260 total beds). Phase 2 (educational intervention using CPGs) and Phase 3 (outcomes) reexamined VTE-P at the same 17 centers.
The frequency of indications for VTE-P and contraindications to anticoagulation were similar during Phases 1 and 3 (all P > .05). In Phase 3, use of aspirin alone decreased more than 50% (P < .0005), whereas use of compression devices increased (P < .0005). Regression models predicted no relationship between any indication or contraindication and VTE-P in Phase 1 (all P > .05) but identified significant relationships between indication and contraindications and VTE-P in Phase 3 (P = .022 to P < .0005), suggesting adequate understanding of current CPGs following education as the basis for improved VTE-P.
The study confirms the presence of significant comorbidity in LTC residents, many with indications for VTE-P, some with contraindications for anticoagulation. Following educational intervention, more residents received VTE-P, influenced by risk-benefit ratio favoring treatment. These findings suggest that even a modest educational intervention significantly improves provider knowledge pertinent to risk assessment consistent with CPG and more appropriate VTE-P.
根据临床实践指南（CPG）进行静脉血栓栓塞症（VTE）预防的实施在长期护理机构（LTCF）中存在差异。当前的指南建议在进行风险评估后，根据患者的情况个体化地进行静脉血栓栓塞症预防（VTE-P）。在 LTCF 中，不同的合并症、预期寿命、伦理和生活质量问题可能需要独特的方法。本文研究了教育干预前后 LTCF 中的 VTE-P 实践，以使实践模式与 CPG 保持一致。
第 1 阶段（本系列文章的前一篇）确定了评估风险和实施 VTE-P 的当前实践（17 个地理位置不同的 LTCF，3260 张总床位）。第 2 阶段（使用 CPG 的教育干预）和第 3 阶段（结果）在相同的 17 个中心重新检查了 VTE-P。
在第 1 阶段和第 3 阶段，VTE-P 的适应证和抗凝禁忌证的频率相似（均 P >.05）。在第 3 阶段，单独使用阿司匹林的比例下降了 50%以上（P <.0005），而使用压缩设备的比例增加了（P <.0005）。回归模型预测在第 1 阶段，任何适应证或禁忌证与 VTE-P 之间均无关系（均 P >.05），但在第 3 阶段，适应证和禁忌证与 VTE-P 之间存在显著关系（P =.022 至 P <.0005），表明在接受教育后，对当前 CPG 的充分理解是改善 VTE-P 的基础。
该研究证实了 LTC 居民存在显著的合并症，许多患者有 VTE-P 的适应证，有些患者有抗凝禁忌证。在接受教育干预后，更多的患者接受了 VTE-P，这是由治疗的风险-效益比决定的。这些发现表明，即使是适度的教育干预也能显著提高与 CPG 一致的风险评估相关的知识，从而更合理地进行 VTE-P。
