Impact of Introducing Anticoagulation-Related Prescribing Guidelines in a Hospital Setting using Academic Detailing

System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support

Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.

Assessing Anticoagulation Management and Shared Decision-Making Documentation From Providers Participating in the SUPPORT-AF II Study

BACKGROUND

A previously tested intervention featured educational outreach with modified academic detailing (AD) to increase anticoagulation use in patients with atrial fibrillation. Currently, this study compares providers receiving and not receiving AD in terms of inclusion of AD educational topics and shared decision-making elements in documentation.

METHODS

Physicians reviewed themes discussed with providers during AD and evaluated charts for evidence of shared decision-making. Frequencies of documentation of individual items for providers receiving AD versus non-AD providers were compared. To understand baseline documentation practices of AD providers, encounters of AD providers before their AD participation were randomly selected.

RESULTS

There were 113 eligible encounters in the four months after AD-36 from AD providers and 77 from non-AD providers. Thirty-five encounters were identified from AD providers before participating in the intervention. Providers infrequently documented many reviewed items (% documenting): anticoagulation mentioned (44%), multiple options for anticoagulation (5%), CHA2DS2-VASc score (11%), bleeding risk factors (2%). Compared with non-AD providers, AD providers had statistically significant higher percentages for the following items: mention of anticoagulation (64% versus 35%), stroke risk (11% versus 0%), anticoagulation benefits (8% versus 0%), and patient involvement (17% versus 0%). There was no improvement, however, for AD providers compared with baseline documentation percentages.

DISCUSSION

Providers infrequently documented important items in anticoagulation management and shared decision-making. AD participation did not improve documentation. Improving adoption of AD educational items may require more prolonged interaction with providers. Improving shared decision-making may require an intervention more focused on it and its documentation.

Implications of an inpatient warfarin dosing nomogram on safety outcomes post-discharge

Many hospitals have implemented warfarin dosing nomograms to improve patient safety. To our knowledge, no study has assessed the impact inpatient warfarin initiation has in both medical and surgical patients, on safety outcomes post discharge. To evaluate the impact of a suggested institutional nomogram for the initiation of warfarin, the primary endpoint was the incidence of bleeding throughout follow up. Secondary endpoints included the composite of INR changes ≥0.5/day and INR >4. Patients were followed for a period of 2 weeks post-discharge. The composite endpoint was evaluated for an effect on reaching therapeutic INR, time to reach therapeutic INR, and bleeding events throughout follow up. A single center retrospective study comparing the safety of adherence vs. non-adherence to a warfarin nomogram. A total of 206 patients were included, 73 patients in the nomogram adherence vs. 133 in the nonadherence arm. There was no difference in the proportion of patients who bled throughout the follow up period, adherence 9.6% vs. nonadherence to the nomogram 13.5%, p = 0.407. There was however a statistical difference in the mean total number of bleeding events, 0.096 (7/73) in the adherence vs. 0.158 (21/133) in the non-adherence arm, p = 0.022. There was also no difference in the composite endpoint, 19.2% in the adherence vs. 28.6% in the non-adherence arm p = 0.180. A positive correlation between the inpatient composite and risk of bleeding throughout follow up was noted. The findings of this study support adherence to the nomogram as opposed to non-adherence.

Advancing the Pain Agenda in the Veteran Population

The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.

Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study

BACKGROUND

Despite the availability of evidence-based guidelines on venous thromboembolism (VTE) prevention clinical audit and research reveals that hospitalised medical patients frequently receive suboptimal prophylaxis. The aim of this study was to evaluate the acceptability, utility and clinical impact of an educational outreach visit (EOV) on the provision of VTE prophylaxis to hospitalised medical patients in a 270 bed acute care private hospital in metropolitan Australia.

METHODS

The study used an uncontrolled before-and-after design with accompanying process evaluation. The acceptability of the intervention to participants was measured with a post intervention survey; descriptive data on resource use was collected as a measure of utility; and clinical impact (prophylaxis rate) was assessed by pre and post intervention clinical audits. Doctors who admit >40 medical patients each year were targeted to receive the intervention which consisted of a one-to-one educational visit on VTE prevention from a trained peer facilitator. The EOV protocol was designed by a multidisciplinary group of healthcare professionals using social marketing theory.

RESULTS

Nineteen (73%) of 26 eligible participants received an EOV. The majority (n = 16, 85%) felt the EOV was effective or extremely effective at increasing their knowledge about VTE prophylaxis and 15 (78%) gave a verbal commitment to provide evidence-based prophylaxis. The average length of each visit was 15 minutes (IQ range 15 to 20) and the average time spent arranging and conducting each visit was 92 minutes (IQ range 78 to 129). There was a significant improvement in the proportion of medical patients receiving appropriate pharmacological VTE prophylaxis following the intervention (54% to 70%, 16% improvement, 95% CI 5 to 26, p = 0.004).

CONCLUSIONS

EOV is effective at improving doctors' provision of pharmacological VTE prophylaxis to hospitalised medical patients. It was also found to be an acceptable implementation strategy by the majority of participants; however, it was resource intensive requiring on average 92 minutes per visit.

Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective and cost-effective. Despite this, prophylactic therapies for VTE are underutilized. System-wide interventions may be more effective to improve the use of VTE prophylaxis than relying on individual providers' prescribing behaviors.

OBJECTIVES

To assess the effects of interventions designed to increase the implementation of thromboprophylaxis in hospitalized adult medical and surgical patients at risk for venous thromboembolism (VTE), assessed in terms of: 1. Increase in the proportion of patients who receive prophylaxis and appropriate prophylaxis 2. Reduction in risk of symptomatic VTE3. Reduction in risk of asymptomatic VTE4. Safety of the intervention.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Group's Specialised Register (last searched July 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) 2010, Issue 3. We searched the PubMed, EMBASE, and SCOPUS databases (19 April 2010) as well as the reference lists of relevant review articles.

SELECTION CRITERIA

We included all studies whose interventions aimed to increase the use of prophylaxis and/or appropriate prophylaxis, decrease the proportion of symptomatic VTE, or decrease the proportion of asymptomatic VTE in hospitalized adult patients. We excluded studies that simply distributed published guidelines and studies whose interventions were not clearly described.

DATA COLLECTION AND ANALYSIS

We collected the following outcomes: the proportion of patients who received prophylaxis (RP), the proportion of patients who received appropriate prophylaxis (RAP) (primary outcomes), and the occurrence of symptomatic VTE, asymptomatic VTE, and safety outcomes such as bleeding. We categorized interventions into education, alerts, and multifaceted interventions. We meta-analyzed RCTs and non-randomized studies (NRS) separately by random effects meta-analysis, and assessed heterogeneity using the I(2)statistic and subgroup analyses. Before analysis, we decided that results would be pooled if three or more studies were available for a particular intervention. We assessed publication bias using funnel plots and cumulative meta-analysis.

MAIN RESULTS

We included a total of 55 studies. One of these reported data in patient-days and could not be quantitatively analyzed with the others. The 54 remaining studies (8 RCTs and 46 NRS) eligible for inclusion in our quantitative synthesis enrolled a total of 78,343 participants. Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders or stickers on patients' charts, were associated with a risk difference (RD) of 13%, signifying an increase in the proportion of patients who received prophylaxis (95% confidence interval (CI) 1% to 25%). Among NRS, there were sufficient data to pool both primary outcomes for each intervention type. Pooled risk differences for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest pooled effects. I(2) results showed substantial statistical heterogeneity which was in part explained by patient types and type of hospital. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Results for VTE and safety outcomes did not show substantial benefits or harms, although most studies were underpowered to assess these outcomes.

AUTHORS' CONCLUSIONS

We reviewed a large number of studies which implemented a variety of system-wide strategies aimed to improve thromboprophylaxis rates in many settings and patient populations. We found statistically significant improvements in prescription of prophylaxis associated with alerts (RCTs) and multifaceted interventions (RCTs and NRS), and improvements in prescription of appropriate prophylaxis in NRS with the use of education, alerts and multifaceted interventions. Multifaceted interventions with an alert component may be the most effective. Demonstrated sources of heterogeneity included patient types and type of hospital. The results of our review will help physicians, nurses, pharmacists, hospital administrators and policy makers make practical decisions about local adoption of specific system-wide measures to improve prevention of VTE, an important public health issue. We did not find a significant benefit for VTE outcomes; however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.

Training pharmacists to deliver a complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis

OBJECTIVE

To describe the training undertaken by pharmacists employed in a pharmacist-led information technology-based intervention study to reduce medication errors in primary care (PINCER Trial), evaluate pharmacists' assessment of the training, and the time implications of undertaking the training.

METHODS

Six pharmacists received training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation forms were entered onto a Microsoft Excel spreadsheet, independently checked and the summary of results further verified. Frequencies were calculated for responses to the three-point Likert scale questions. Free-text comments from the evaluation forms and pharmacists' diaries were analysed thematically.

KEY FINDINGS

All six pharmacists received 22 h of training over five sessions. In four out of the five sessions, the pharmacists who completed an evaluation form (27 out of 30 were completed) stated they were satisfied or very satisfied with the various elements of the training package. Analysis of free-text comments and the pharmacists' diaries showed that the principles of root cause analysis and educational outreach were viewed as useful tools to help pharmacists conduct pharmaceutical interventions in both the study and other pharmacy roles that they undertook. The opportunity to undertake role play was a valuable part of the training received.

CONCLUSIONS

Findings presented in this paper suggest that providing the PINCER pharmacists with training in root cause analysis and educational outreach contributed to the successful delivery of PINCER interventions and could potentially be utilised by other pharmacists based in general practice to deliver pharmaceutical interventions to improve patient safety.

A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers

AIMS

Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions.

METHODS

Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument.

RESULTS

Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective.

CONCLUSION

Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.

Testing the effect of a targeted intervention on nurses' compliance with "best practice" mechanical venous thromboembolism prevention

The aim of this study was to examine whether educational outreach visits improve nurses' compliance with applying best practice mechanical venous thromboembolism prophylaxis. The design was as a pretest/posttest study with a 7-week follow-up. It was conducted in a mixed medical/surgical unit in a 250-bed private hospital in Sydney, Australia. The target population was 25 medical/surgical nurses in educational outreach visits (EOVs). The main outcome measures included change in percentage between baseline and endpoint of eligible patients receiving mechanical VTE prophylaxis and all patients having VTE risk documented in their medication charts, as well as nurses' feedback on how supportive and useful they found EOVs. The results showed an overall, but not significant increase (p = 0.201) in the percentage of patients who received mechanical VTE prophylaxis (59.4% baseline to 75% endpoint). There was a significant increase in the percentage of patients having VTE risk status documented in the medication chart (0%-28%) (p = 0.002). Improvements in compliance were more likely for surgical than medical patients (95% and 35%, respectively) and risk documentation (47% and 6%, respectively). Most nurses reported that the EOVs supported them in implementing best practice VTE mechanical prophylaxis. Researchers conclude that improvements in compliance with best practice VTE prevention can be achieved using EOVs which were easily conducted and well-received in a busy unit setting. More work is needed to increase the compliance rate with medical patients.

Impact of discrepant results from clinical laboratories on patients and pharmaceutical trials: evidence from proficiency testing results

Aims: Despite improvements achieved in laboratory medicine over the years, discrepant results from different clinical laboratories are still a source of imminent risk to patients and the pharmaceutical industry. The problem is aggravated by a disconnection between laboratorians and clinicians or drug developers. Materials & methods: In this report, results from proficiency testing, originally established as a tool for good laboratory practice, were used to highlight the size of the problem and its impact on patients and pharmaceutical trials. Results from three laboratory tests, believed to be standardized and commonly requested as tools in the management of patients, and decision-making biomarkers in drug development were used: prothrombin time expressed as international normalization ratio, digoxin and low-density lipoprotein-cholesterol. Results: Unfortunately, data demonstrate that results for the same sample or batch of samples, if analyzed by different laboratories or even by one laboratory that employs different platforms or reagents, can be extremely different. Conclusion: In the absence of an effective laboratory-to-laboratory, method-to-method or platform-to-platform standardization, or at lowest harmonization of test results, laboratory results could be misleading to clinicians and the drug industry. Drug developers need to understand the current challenge before any attempt to use biomarker data to make decisions, compile data for a biomarker from different studies or use biomarkers to bridge between different drug candidates belonging to a particular class of compounds.