Woller Scott C, Stevens Scott M, Evans R Scott, Wray Daniel, Christensen John, Aston Valerie T, Wayne Matthew, Lloyd James F, Wilson Emily L, Elliott C Gregory
Department of Medicine Intermountain Medical Center Murray UT USA.
Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT USA.
Res Pract Thromb Haemost. 2018 Jun 7;2(3):481-489. doi: 10.1002/rth2.12119. eCollection 2018 Jul.
Venous thromboembolism prophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We previously reported that a multifaceted intervention was associated with a sustained increase in appropriate thromboprophylaxis and reduced symptomatic venous thromboembolism among medical patients hospitalized in two urban teaching hospitals. The effectiveness of this intervention in community hospitals is unknown.
We performed a prospective multicenter cohort study in three community hospitals. All medical patients admitted from February 1, 2011 to January 31, 2014 were eligible. Consecutive eligible patients were enrolled into the 12-month "control," 12-month "intervention," or 12-month "maintenance" group. We provided electronic alerts, physician performance feedback, and targeted medical education for the intervention group. Only the alert component of the intervention continued in the maintenance group. The primary outcome was the rate of appropriate thromboprophylaxis among patients at high risk for venous thromboembolism defined as the prescription of guideline recommended chemoprophylaxis, or identification of a chemoprophylaxis contraindication. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue.
Appropriate thromboprophylaxis when compared to the control group rate of 67% was higher for the intervention group (85%) and for the maintenance group (77%; <.001 for each comparison). A reduction of 90-day symptomatic venous thromboembolism accompanied the intervention (control 4.5%, intervention 3.4%, maintenance 3.0%, =.04).
This multifaceted intervention was associated with an overall increase in appropriate thromboprophylaxis of medical patients compared with the control period. Hospital-associated venous thrombosis rates decreased.
在静脉血栓栓塞风险较高的住院内科患者中，静脉血栓栓塞预防措施的应用仍未得到充分利用。我们之前报告称，在两家城市教学医院住院的内科患者中，多方面干预措施与适当血栓预防的持续增加以及有症状静脉血栓栓塞的减少有关。这种干预措施在社区医院的有效性尚不清楚。
我们在三家社区医院进行了一项前瞻性多中心队列研究。2011年2月1日至2014年1月31日期间收治的所有内科患者均符合条件。连续符合条件的患者被纳入12个月的“对照组”、12个月的“干预组”或12个月的“维持组”。我们为干预组提供电子警报、医生绩效反馈和针对性医学教育。维持组仅继续干预措施中的警报部分。主要结局是静脉血栓栓塞高风险患者中适当血栓预防的发生率，定义为指南推荐的化学预防药物的处方，或化学预防禁忌证的识别。次要结局包括有症状静脉血栓栓塞、大出血、全因死亡率、肝素诱导的血小板减少症、医生满意度和警报疲劳的发生率。
与对照组67%的发生率相比，干预组（85%）和维持组（77%；每次比较P<.001）的适当血栓预防发生率更高。干预措施伴随着90天有症状静脉血栓栓塞的减少（对照组4.5%，干预组3.4%，维持组3.0%，P=.04）。
与对照期相比，这种多方面干预措施与内科患者适当血栓预防的总体增加有关。医院相关静脉血栓形成率降低。
