Published in the August 2005 issue of Today’s Hospitalist
A recent study of a computer-based alert to encourage physicians to order prophylaxis for deep-vein thrombosis and pulmonary embolism may hold some important lessons for hospitalists.
During the study, researchers at the Brigham and Women’s Hospital in Boston used a computer alert to identify patients at risk for DVT and encourage physicians to order prophylaxis.
The computer program examined patient records and looked for eight risk factors (see “How one computer system identified patients who were at risk for a thrombotic event,” next page) to determine individuals who faced an increased risk of DVT. The system then sent an electronic alert to the intern or resident in charge of the patient.
The alert gave the physician a link to the hospital’s VTE-prevention guidelines. The member of the housestaff had to acknowledge the alert and could decide to order prophylaxis or ignore the warning.
When researchers examined whether the electronic alert system had any impact on the prevalence of DVT or PE at 90 days, they found physicians who received a DVT alert ordered prophylaxis more than twice as often as physicians who didn’t receive an alert. Housestaff ordered prophylactic measures for 33 percent of patients in the intervention group. In the control group, by comparison, similar measures were ordered for only 14.5 percent of patients.
Patients in the intervention group had higher rates of mechanical prophylaxis (10 percent vs. 1.5 percent) and pharmacologic prophylaxis (23.6 percent vs. 13 percent) than their counterparts in the control group.
By doubling the numbers of patients who received prophylaxis, the alerts helped reduce the overall rate of VTE at 90 days by 41 percent. Perhaps just as important, there was no increase in bleeding or mortality.
Trouble for medical patients
The study, which was published in the March 10, 2005, New England Journal of Medicine, acknowledges that the rate of prophylaxis in the intervention group “33.5 percent “was low.
Almost two-thirds of patients faced a high enough risk of DVT that an alert was issued, for example, and nearly 38 percent had a relatively high risk of a thrombotic event. In an ideal world, many more of those patients would have also received prophylaxis.
“While a 41 percent reduction in VTE is quite spectacular, that could be even better,” says Samuel Z. Goldhaber, MD, the study’s architect and a co-author of the article. The study’s results, he adds, have particularly troubling implications for internists.
He explains that almost 83 percent of the subjects in the study who faced a high risk of DVT but did not receive prophylaxis were medical, not surgical, patients, and they were largely cared for by internal medicine residents. The fact that relatively few received prophylaxis, he says, points to an opportunity for internists in general “and hospitalists in particular “to do a better job of DVT prevention.
“This is a problem that falls right into the turf of the hospitalist,” says Dr. Goldhaber, who is associate professor of medicine at Harvard Medical School and director of the venous thromboembolism research group at the Brigham.
“The surgeons by and large are doing an excellent job of prophylaxis. We in internal medicine need to clean our own houses and make sure that our high-risk patients are receiving prophylaxis against DVT and PE.”
And while some may argue that medical patients may face a higher risk of reactions to pharmacologic prophylaxis than surgical patients, Dr. Goldhaber is quick to point out that those patients can receive mechanical prophylaxis.
Interestingly, housestaff in the study embraced nonpharmacologic prophylaxis. Much of the overall increase in prophylaxis found by the study was the result of an increase in mechanical, not pharmacologic, prophylaxis, a result that Dr. Goldhaber says he found surprising.
So why didn’t more patients receive prophlyaxis? While the study didn’t examine the attitudes of housestaff, Dr. Goldhaber notes that one thing is clear: “We cannot assume that trainees are maximizing the use of prophylaxis, even though they attend lectures and seminars and are directed to Web sites about the rationale for prophylaxis.”
The good news from the study is that a simple computer alert system can give a quick boost to prophylactic rates. An accompanying editorial notes that by using the intervention in just 30 patients, one DVT or PE can be prevented.
While the study urges hospitals with information systems to consider adding this to the list, Dr. Goldhaber says that hospitals can implement a simpler version of the alert system without a sophisticated computer system.
“You don’t need a computer to do this,” he explains. “You can have a top-notch nurse or physicians assistant go around the hospital, see who was admitted the night before, go to the bedside, take the risk assessment score, determine the risk level and then determine whether the patient is receiving prophylaxis. If the patient is not receiving prophylaxis, the nurse can page the doctor in charge.”
Dr. Goldhaber adds that there was another positive, if surprising, outcome of the study: Even when physicians did not order prophlyaxis for patients who faced a high risk of DVT, outcomes for the intervention group showed a slight improvement.
The article concludes that assignment to the intervention group alone appeared to reduce thrombotic events. It hypothesizes that the computer alert, even if it wasn’t directly heeded, may have made physicians more alert to the possibility of a PE or DVT.
Dr. Goldhaber says this result, which is often referred to as a “halo effect” of quality improvement research, is a mysterious but welcome outcome.
“I don’t know exactly what happened,” he says, “whether physicians got those patients out of bed sooner or discharged them sooner, but there was something about being alerted that led to fewer DVTs and PEs,” even when prophylaxis was not administered.
Edward Doyle is Editor of Today’s Hospitalist.