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VTE Prevention in VA Hospitals
Pulmonary embolism (PE) is the most common preventable cause of death in hospitals,1 accounting for approximately 10% of hospital deaths. Most cases of PE result from dislodged lower extremity thrombi, so that deep vein thrombosis (DVT) and PE are manifestations of the same disorder, venous thromboembolism (VTE). Even though the majority of hospitalized patients are at increased risk for VTE and proven preventive measures have long been available, most patients do not receive appropriate care.2
Recent surgery is a well‐recognized risk factor for VTE, and surgeons have prescribed prophylactic therapies more consistently than other specialists.3 At the same time, prevention of VTE among hospitalized medical patients has been neglected.4 The American College of Chest Physicians recommends pharmacologic VTE prevention for most acutely ill medical patients, and advises prevention using mechanical devices when pharmacologic intervention is contraindicated.1
In Department of Veterans Affairs (VA) hospitals, compliance with preventive guidelines in surgical patients has been high. During October through December 2007, according to the Office of Quality and Performance, Veterans Health Administration, the national average for administration of VTE prophylaxis within 24 hours of surgery in VA hospitals was 92%. No comparable systemwide performance measure has been applied for medical patients, but an assessment involving intensive care unit patients has been completed and plans are underway for an evaluation of anticoagulant use among all inpatients considered to be at increased risk.
We sought to determine the extent to which hospitalized VA medical patients receive VTE preventive care in accordance with evidence‐based recommendations. Because quality of care may vary in hospitals based on teaching status,5 a secondary goal was to ascertain whether teaching and nonteaching facilities differ with respect to the delivery of care for VTE prevention.
Patient Populations Methods
We examined compliance with accepted VTE clinical practice guidelines in 2 patient populations. First, the care of patients at risk for developing VTE was evaluated for evidence of appropriate preventive measures. Second, the care of patients who developed PE while hospitalized was evaluated for evidence of preventive therapy prior to the event.
We identified patients discharged from VA acute care hospitals during the period April 1, 2006 to March 31, 2007, excluding patients hospitalized for less than 48 hours. We also excluded hospitalizations of VA patients at military and private hospitals because oversight of the quality of care provided at those facilities is beyond the purview of the Inspector General.
We then defined 2 distinct populations:
Medical patients at increased risk for VTE. These patients were identified by: (1) age 75 years at the time of admission; and (2) hospitalization with a principal discharge diagnosis of heart failure (International Classification of Diseases, 9th edition [ICD‐9] code 428). Elderly heart failure patients were chosen because advanced age and heart failure are recognized VTE risk factors, medical inpatients have been identified as being neglected in hospital VTE prevention efforts, and the VA was conducting no systemwide assessment of this aspect of care.
Patients with established PE. These patients had any discharge diagnosis pulmonary embolism and infarction (ICD‐9 codes 415.1 or 415.19), but those with the diagnostic code personal history of venous thrombosis and embolism (V12.51) were excluded.
Within each population, the discharge date defined an index hospitalization for evaluation. For patients discharged more than once with a qualifying diagnosis during the study period, we analyzed only the most recent hospitalization.
Characterization of Facilities
Hospitals were considered teaching hospitals if they were members of the Association of American Medical Colleges' Council of Teaching Hospitals and Health Systems (COTH).6 When COTH membership was through a Veterans Integrated Service Network, hospitals were judged to be teaching hospitals if they had 1 or more close university affiliations and/or management of medical inpatients by house staff.
Patient Selection and Medical Record Review
In order to ensure optimal representation of teaching and nonteaching hospitals, we stratified patients with increased VTE risk and those with diagnosed PE according to hospital teaching status, thereby creating 4 groups:
Patients at increased risk for VTEteaching hospitals;
Patients at increased risk for VTEnonteaching hospitals;
PE patientsteaching hospitals;
PE patientsnonteaching hospitals.
Within each group we assigned a random number to each patient, ordered the patients by random number, and selected patients sequentially until 50 patients were identified or no further eligible patients were available. For the heart failure patients, we assumed that all were at risk for VTE and required prophylaxis. For the group of patients with established PE, we excluded patients if the diagnosis was made prior to admission or in the first 2 hospital days, if there were no acute signs and symptoms and the diagnosis was chronic PE, or if there were no imaging studies or postmortem findings in support of the diagnosis.
In both groups, we assessed patients' records for VTE risk factors, evidence of preventive care, and contraindications.7 We considered pertinent VTE risk factors to be those included with published guidelines.1 In the care of patients with established PE, designation of adequate prophylactic therapy required at least 24 hours of treatment prior to diagnosis.
Appropriate VTE prophylaxis was defined as anticoagulant medications or, in the case of contraindications to anticoagulation, mechanical compression devices applied to the lower extremities with or without antiembolism stockings. Any administration of warfarin, lowmolecular‐weight heparin, or heparin by infusion, was considered adequate. Prophylaxis with subcutaneous unfractionated heparin was considered adequate only if at least 5000 units was administered 3 times daily.8 Aspirin and other antiplatelet agents were not considered to be anticoagulants.
We characterized hospitalizations of at‐risk individuals as missed opportunities for prevention if there were no contraindications to treatment and no evidence that adequate prophylactic therapy was provided.
Data Analysis
To determine sample size for each of the 2 study populations, we assumed the baseline rate of compliance with recommendations for VTE prophylaxis among medical inpatients to be 0.4 to 0.5.4 We further assumed that an observed compliance rate of 0.7 would be indicative of an important difference compared with published results (rate difference, 0.2‐0.3). With a Type 1 (alpha) error of 0.025 (1‐tailed), approximately 90 patients are required for a 0.9 probability of detecting a difference of at least 0.25.9
Comparisons between teaching and nonteaching hospitals were analyzed using chi‐square tests. Confidence intervals for estimates of overall compliance were calculated using a normal approximation to the binomial distribution.10
Results
Medical Patients at Increased Risk for VTE
We identified 4963 patients age 75 and older discharged after at least 2 days of acute hospitalization for heart failure: 3437 from 73 teaching hospitals and 1526 from 58 nonteaching hospitals. The 100 patients randomly selected for review ranged in age from 75 to 94 (median, 82) and had hospitalizations of 3 to 41 days (median, 6). Ninety‐eight were male. In this group of patients, we found 63 with evidence of adequate pharmacologic VTE prevention and 37 for which opportunities for prevention were not realized. At teaching hospitals, anticoagulation was effected with warfarin (13 cases), heparin (11), and enoxaparin (10). At nonteaching hospitals anticoagulants included warfarin (16), enoxaparin (11), and heparin (2). Twenty‐nine of the 63 patients who received anticoagulation (46%) were admitted while taking warfarin for chronic conditions. Teaching and nonteaching hospitals did not differ with respect to missed opportunities for prevention of VTE (37% in each group; Table 1).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 4963 | 3437 | 1526 |
| Randomly selected patients at risk | 100 | 54 | 46 |
| Received prophylactic anticoagulation | 63 | 34 | 29 |
| Missed opportunities for prevention | 37 | 20 | 17 |
| Percent (95% confidence interval) | 37 (27‐47) | 37 (23‐51) | 37 (22‐52) |
Patients With Established PE
We identified 1448 acute hospitalizations of at least 2 days duration for patients with PE, 1118 from 72 teaching hospitals and 330 from 51 nonteaching hospitals. We reviewed 779 medical records, 449 (40.2%) teaching cases and all 330 nonteaching cases. Chart review was completed after all nonteaching cases had been reviewed. In only 8.2% (64) of reviewed cases was the diagnosis of acute PE made after the first 2 hospital days and with accompanying objective evidence of VTE. Most cases (698; 89.6%) were excluded because there was only a remote history of PE or the diagnosis was made prior to admission. Additional cases (17; 2.2%) were excluded because the diagnosis was made during the first 2 hospital days; there were no acute signs and symptoms and the diagnosis was chronic PE; or there was no confirmation by computed tomography or ventilation‐perfusion scans, lower extremity ultrasonography in the setting of consistent clinical findings, or autopsy.
The 64 patients with confirmed in‐hospital PE ranged in age from 44 to 85 years (median, 65) and had hospitalizations of 4 to 53 days (median, 16). Sixty‐three were male. One of these patients had no definite risk factors for VTE and was ambulatory when acute symptoms occurred. Among the 63 patients who had unequivocal VTE risk factors, 34 (54%) received appropriate prophylactic treatment, and 29 (46%) received inadequate or no preventive therapy (Table 2). There was no significant difference between teaching and nonteaching hospitals with respect to missed opportunities for prevention (49% vs. 35%; P 0.3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 1448 | 1118 | 330 |
| Randomly selected patients | 779 | 449 | 330 |
| Documented in‐hospital pulmonary embolism | 64 | 47 | 17 |
| No definite VTE risk factors | 1 | 0 | 1 |
| Received prophylactic anticoagulation | 30 | 20 | 10 |
| Anticoagulation contraindicated, received mechanical prophylaxis | 4 | 4 | 0 |
| Missed opportunities for prevention | 29 | 23 | 6 |
| Percent (95% confidence interval) | 45 (32‐58) | 49 (30‐68) | 35 (12‐58) |
Anticoagulants used at teaching hospitals included heparin (15 cases), enoxaparin (4), and warfarin (1), while at nonteaching hospitals enoxaparin (7) and heparin (3) were used.
Each of the 10 patients who received no anticoagulation had the VTE risk factor of recent immobility prior to PE. Nine of the 10 had active malignancies, and 4 of these had undergone recent surgery. None had evidence of hypercoagulable states (factor V Leiden, lupus anticoagulant, or anticardiolipin antibodies). Five of the 10 patients died in the year following pulmonary embolism, 3 prior to discharge or within 2 weeks of discharge.
Missed Opportunities for Prevention
Among the 66 patients whose hospitalizations were characterized as missed opportunities for prevention, 30 received no pharmacologic VTE prevention despite having no contraindications. Seven patients had contraindications to pharmacologic prophylaxis, but none of these patients had contraindications to mechanical prophylaxis. An additional 18 patients received mechanical prophylaxis only despite having no contraindications to anticoagulation. Eleven patients received inadequate heparin regimens with or without mechanical prophylaxis (Table 3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| Number of patients | 66 | 43 | 23 |
| No contraindications, no prophylaxis | 30 | 18 | 12 |
| Anticoagulation contraindicated, no mechanical prophylaxis | 7 | 3 | 4 |
| No contraindication to anticoagulation, mechanical prophylaxis only | 18 | 13 | 5 |
| Inadequate heparin regimen, no mechanical prophylaxis | 9 | 7 | 2 |
| Inadequate heparin regimen, mechanical prophylaxis | 2 | 2 | 0 |
Discussion
Based on a random sample of 4963 elderly heart failure patients admitted to VA hospitals during a 1‐year period, we estimated that 63% received recommended interventions aimed at preventing VTE. Although differences in methodology limit comparisons with published reports, this rate is similar to those observed at individual hospitals,1113 in large multicenter registries of patients with DVT or at risk for VTE,14, 15 and in a recent multinational cross‐sectional study.16 Notably, chronic outpatient anticoagulation that was continued during hospitalization accounted for nearly one‐half of patients receiving preventive care. Compliance did not differ between teaching and nonteaching hospitals.
In a complementary approach to examining the extent of preventive care, we identified 1448 patients discharged with a diagnosis of PE. Most of these patients were excluded because they did not have a new event while hospitalized. Eleven (17%) of the 64 patients with confirmed in‐hospital PE received no preventive care before the event. An additional 18 (28%) received suboptimal heparin regimens or mechanical prophylaxis in the absence of contraindications to anticoagulation. As with the patients at risk for VTE, patients with established PE at teaching and nonteaching hospitals received similar rates of preventive care. Contrary to our expectation, the observed difference in rates between types of hospitals favored nonteaching hospitals. However, the sample size for this comparison was small and the difference did not reach statistical significance.
This study's population‐based approach permits conclusions about the performance of the VA's entire system of acute care hospitals. The results indicate that proven preventive therapies are often neglected at VA hospitals, but overall performance is probably comparable to other settings. VA employs an extensively implemented electronic medical record (EMR) and superior performance might have been expected. However, these results suggest limitations in the EMR as it is currently deployed. Successful efforts probably require a multifaceted approach incorporating decision support and institutional standardization.17
Several additional findings warrant comment. Patients with malignancies accounted for 9 of 10 patients who had PE after receiving no prior anticoagulation. Recent surgery was also a contributing factor for 4 of these cancer patients. Although both cancer and surgery are well‐known risk VTE factors, clinicians may not appreciate the extremely high risk associated with the combination.18 Particular effort may be warranted to ensure prophylaxis in this group, and more intensive measures may be necessary.
These results reveal several barriers to the accurate retrospective measurement of preventable inpatient PE. First, the use of discharge diagnoses to monitor the occurrence of inpatient PE is fraught with hazard. In this study, even after excluding patients with a discharge diagnostic code indicating a past history of PE, very few identified patients in fact had an acute or recent event. In addition, many patients were clearly admitted after having the onset of symptoms as outpatients. Further, reliance on discharge diagnoses alone can lead to the inclusion of patients with a presumptive diagnosis made without the advantage of imaging studies or postmortem examination. Although we overcame these barriers through careful record review and strict diagnostic criteria, our results suggest that efficient performance improvement efforts may require ongoing concurrent review.
There are several limitations of this study. First, we excluded PE patients whose diagnoses were made before the third hospital day. Some of these patients may have had events attributable to recent prior hospitalizations and should have received VTE prophylaxis. Second, we considered preventive measures applied at least 24 hours prior to PE to be acceptable evidence of prevention, potentially neglecting prior periods without treatment that might confer increased risk. Bias due to either of these limitations could exaggerate the compliance rates we report. Finally, the retrospective design of this study did not allow for consistent assessments of whether patients had the risk factor of immobility. Nevertheless, immobility was obvious for the 10 patients with PE who had no prior anticoagulation, all of whom had 2 or more risk factors.
Despite an acknowledged need for improvements in clinical practice, past efforts have had mixed results. For instance, in 1 study at a hospital with a well‐established EMR, computer alerts led to substantial improvement in the use of preventive measures and in VTE outcomes, but overall compliance remained low.19 On the other hand, a multidisciplinary approach can achieve marked reductions in preventable VTE events.20 Key elements of such an approach are a simplified risk assessment tool and concurrent monitoring of patient treatments and outcomes. The Agency for Healthcare Research and Quality has recently published a guide that outlines strategies for achieving breakthrough levels of improvement in the prevention of VTE.21
In conclusion, this population‐based study of hospitalized veterans with PE or at risk for VTE found compliance comparable to rates in published reports. Missed opportunities for prevention included inappropriate and inadequate interventions. Using discharge diagnoses to monitor the occurrence of inpatient PE is of limited value, and efficient performance improvement efforts may require ongoing concurrent review.
Acknowledgements
The authors thank Greg Maynard, MD, MS for advice on study design, and Deborah Howard, RN, for assistance with medical record review.
- ,,.Prevention of venous thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest.2004;126:338S–400S.
- ,,,.Thromboprophylaxis rates in US medical centers: success or failure?J Thromb Haemost.2007;5:1610–1616.
- .Preventing venous thromboembolism in surgical patients.Cleve Clin J Med.2006;73:S88–S94.
- ,.Prevention of venous thromboembolism among hospitalized medical patients.Circulation.2005;111:e1–e3.
- ,,.Quality of care for the treatment of acute medical conditions in US hospitals.Arch Intern Med.2006;166:2511–2517.
- Association of American Medical Colleges (AAMC). Council of Teaching Hospitals and Health Systems (COTH). Available at: http://www.aamc. org/members/coth. Accessed August2009.
- Contraindications are those described in the Institute for Clinical Systems Improvement Health Care Guideline: Venous Thromboembolism Prophylaxis. 4th ed. June 2007, pp 13–14. Available at: http://www. icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/venous_thromboem bolism_prophylaxis/venous_thromboembolism_prophylaxis_5.html. Accessed August2009.
- ,,, et al.Prevention and treatment of venous thromboembolism. International Consensus Statement.Int Angiol.2006;25:101–161.
- ,.Designing Clinical Research.Baltimore, MD:Williams 1988.
- ,,. Statistical Methods for Rates and Proportions.3rd ed.Hoboken, NJ:Wiley‐Interscience;2003;28,54.
- ,,.New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment.Chest.2000;118;1680–1684.
- ,,.Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study.Pharmacotherapy.2006;26:1086–1090.
- ,,.Hospital‐acquired venous thromboembolism and prophylaxis in an integrated hospital delivery system.J Clin Pharm Ther.2006;31:455–459.
- ,;DVT FREE Steering Committee.A prospective study of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;15:259–262.
- ,,, et al.Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism.Chest.2007;132:936–945.
- ,,, et al.Venous thromboembolism risk and prophylaxis in the acute hospital care setting.Lancet.2008;371:387–394.
- .Medical admission order sets to improve deep vein thrombosis prevention: a model for others or a prescription for mediocrity?J Hosp Med.2009;4:77–80.
- ,,,,,.Prevention of venous thromboembolism in the cancer surgery patient.Cleve Clin J Med.2008;75(suppl 3):S17–S26.
- ,,, et al.Electronic alerts for hospitalized high‐VTE risk patients not receiving prophylaxis: a cohort study.J Thromb Thrombolysis.2008;25:146–150.
- ,,, et al. Prevention of hospital‐acquired venous thromboembolism: prospective validation of a VTE risk assessment model and protocol. Society of Hospital Medicine 2008 National Meeting. Electronic citation abstract #52, page 29. Available at: http://www.hospital medicine.org/Paperless2008/PDFs/Additional_Info/SHM08_Abstracts.pdf. Accessed August2009
- ,.Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ Publication No. 08–0075.Rockville, MD:Agency for Healthcare Research and Quality;2008.
Pulmonary embolism (PE) is the most common preventable cause of death in hospitals,1 accounting for approximately 10% of hospital deaths. Most cases of PE result from dislodged lower extremity thrombi, so that deep vein thrombosis (DVT) and PE are manifestations of the same disorder, venous thromboembolism (VTE). Even though the majority of hospitalized patients are at increased risk for VTE and proven preventive measures have long been available, most patients do not receive appropriate care.2
Recent surgery is a well‐recognized risk factor for VTE, and surgeons have prescribed prophylactic therapies more consistently than other specialists.3 At the same time, prevention of VTE among hospitalized medical patients has been neglected.4 The American College of Chest Physicians recommends pharmacologic VTE prevention for most acutely ill medical patients, and advises prevention using mechanical devices when pharmacologic intervention is contraindicated.1
In Department of Veterans Affairs (VA) hospitals, compliance with preventive guidelines in surgical patients has been high. During October through December 2007, according to the Office of Quality and Performance, Veterans Health Administration, the national average for administration of VTE prophylaxis within 24 hours of surgery in VA hospitals was 92%. No comparable systemwide performance measure has been applied for medical patients, but an assessment involving intensive care unit patients has been completed and plans are underway for an evaluation of anticoagulant use among all inpatients considered to be at increased risk.
We sought to determine the extent to which hospitalized VA medical patients receive VTE preventive care in accordance with evidence‐based recommendations. Because quality of care may vary in hospitals based on teaching status,5 a secondary goal was to ascertain whether teaching and nonteaching facilities differ with respect to the delivery of care for VTE prevention.
Patient Populations Methods
We examined compliance with accepted VTE clinical practice guidelines in 2 patient populations. First, the care of patients at risk for developing VTE was evaluated for evidence of appropriate preventive measures. Second, the care of patients who developed PE while hospitalized was evaluated for evidence of preventive therapy prior to the event.
We identified patients discharged from VA acute care hospitals during the period April 1, 2006 to March 31, 2007, excluding patients hospitalized for less than 48 hours. We also excluded hospitalizations of VA patients at military and private hospitals because oversight of the quality of care provided at those facilities is beyond the purview of the Inspector General.
We then defined 2 distinct populations:
Medical patients at increased risk for VTE. These patients were identified by: (1) age 75 years at the time of admission; and (2) hospitalization with a principal discharge diagnosis of heart failure (International Classification of Diseases, 9th edition [ICD‐9] code 428). Elderly heart failure patients were chosen because advanced age and heart failure are recognized VTE risk factors, medical inpatients have been identified as being neglected in hospital VTE prevention efforts, and the VA was conducting no systemwide assessment of this aspect of care.
Patients with established PE. These patients had any discharge diagnosis pulmonary embolism and infarction (ICD‐9 codes 415.1 or 415.19), but those with the diagnostic code personal history of venous thrombosis and embolism (V12.51) were excluded.
Within each population, the discharge date defined an index hospitalization for evaluation. For patients discharged more than once with a qualifying diagnosis during the study period, we analyzed only the most recent hospitalization.
Characterization of Facilities
Hospitals were considered teaching hospitals if they were members of the Association of American Medical Colleges' Council of Teaching Hospitals and Health Systems (COTH).6 When COTH membership was through a Veterans Integrated Service Network, hospitals were judged to be teaching hospitals if they had 1 or more close university affiliations and/or management of medical inpatients by house staff.
Patient Selection and Medical Record Review
In order to ensure optimal representation of teaching and nonteaching hospitals, we stratified patients with increased VTE risk and those with diagnosed PE according to hospital teaching status, thereby creating 4 groups:
Patients at increased risk for VTEteaching hospitals;
Patients at increased risk for VTEnonteaching hospitals;
PE patientsteaching hospitals;
PE patientsnonteaching hospitals.
Within each group we assigned a random number to each patient, ordered the patients by random number, and selected patients sequentially until 50 patients were identified or no further eligible patients were available. For the heart failure patients, we assumed that all were at risk for VTE and required prophylaxis. For the group of patients with established PE, we excluded patients if the diagnosis was made prior to admission or in the first 2 hospital days, if there were no acute signs and symptoms and the diagnosis was chronic PE, or if there were no imaging studies or postmortem findings in support of the diagnosis.
In both groups, we assessed patients' records for VTE risk factors, evidence of preventive care, and contraindications.7 We considered pertinent VTE risk factors to be those included with published guidelines.1 In the care of patients with established PE, designation of adequate prophylactic therapy required at least 24 hours of treatment prior to diagnosis.
Appropriate VTE prophylaxis was defined as anticoagulant medications or, in the case of contraindications to anticoagulation, mechanical compression devices applied to the lower extremities with or without antiembolism stockings. Any administration of warfarin, lowmolecular‐weight heparin, or heparin by infusion, was considered adequate. Prophylaxis with subcutaneous unfractionated heparin was considered adequate only if at least 5000 units was administered 3 times daily.8 Aspirin and other antiplatelet agents were not considered to be anticoagulants.
We characterized hospitalizations of at‐risk individuals as missed opportunities for prevention if there were no contraindications to treatment and no evidence that adequate prophylactic therapy was provided.
Data Analysis
To determine sample size for each of the 2 study populations, we assumed the baseline rate of compliance with recommendations for VTE prophylaxis among medical inpatients to be 0.4 to 0.5.4 We further assumed that an observed compliance rate of 0.7 would be indicative of an important difference compared with published results (rate difference, 0.2‐0.3). With a Type 1 (alpha) error of 0.025 (1‐tailed), approximately 90 patients are required for a 0.9 probability of detecting a difference of at least 0.25.9
Comparisons between teaching and nonteaching hospitals were analyzed using chi‐square tests. Confidence intervals for estimates of overall compliance were calculated using a normal approximation to the binomial distribution.10
Results
Medical Patients at Increased Risk for VTE
We identified 4963 patients age 75 and older discharged after at least 2 days of acute hospitalization for heart failure: 3437 from 73 teaching hospitals and 1526 from 58 nonteaching hospitals. The 100 patients randomly selected for review ranged in age from 75 to 94 (median, 82) and had hospitalizations of 3 to 41 days (median, 6). Ninety‐eight were male. In this group of patients, we found 63 with evidence of adequate pharmacologic VTE prevention and 37 for which opportunities for prevention were not realized. At teaching hospitals, anticoagulation was effected with warfarin (13 cases), heparin (11), and enoxaparin (10). At nonteaching hospitals anticoagulants included warfarin (16), enoxaparin (11), and heparin (2). Twenty‐nine of the 63 patients who received anticoagulation (46%) were admitted while taking warfarin for chronic conditions. Teaching and nonteaching hospitals did not differ with respect to missed opportunities for prevention of VTE (37% in each group; Table 1).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 4963 | 3437 | 1526 |
| Randomly selected patients at risk | 100 | 54 | 46 |
| Received prophylactic anticoagulation | 63 | 34 | 29 |
| Missed opportunities for prevention | 37 | 20 | 17 |
| Percent (95% confidence interval) | 37 (27‐47) | 37 (23‐51) | 37 (22‐52) |
Patients With Established PE
We identified 1448 acute hospitalizations of at least 2 days duration for patients with PE, 1118 from 72 teaching hospitals and 330 from 51 nonteaching hospitals. We reviewed 779 medical records, 449 (40.2%) teaching cases and all 330 nonteaching cases. Chart review was completed after all nonteaching cases had been reviewed. In only 8.2% (64) of reviewed cases was the diagnosis of acute PE made after the first 2 hospital days and with accompanying objective evidence of VTE. Most cases (698; 89.6%) were excluded because there was only a remote history of PE or the diagnosis was made prior to admission. Additional cases (17; 2.2%) were excluded because the diagnosis was made during the first 2 hospital days; there were no acute signs and symptoms and the diagnosis was chronic PE; or there was no confirmation by computed tomography or ventilation‐perfusion scans, lower extremity ultrasonography in the setting of consistent clinical findings, or autopsy.
The 64 patients with confirmed in‐hospital PE ranged in age from 44 to 85 years (median, 65) and had hospitalizations of 4 to 53 days (median, 16). Sixty‐three were male. One of these patients had no definite risk factors for VTE and was ambulatory when acute symptoms occurred. Among the 63 patients who had unequivocal VTE risk factors, 34 (54%) received appropriate prophylactic treatment, and 29 (46%) received inadequate or no preventive therapy (Table 2). There was no significant difference between teaching and nonteaching hospitals with respect to missed opportunities for prevention (49% vs. 35%; P 0.3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 1448 | 1118 | 330 |
| Randomly selected patients | 779 | 449 | 330 |
| Documented in‐hospital pulmonary embolism | 64 | 47 | 17 |
| No definite VTE risk factors | 1 | 0 | 1 |
| Received prophylactic anticoagulation | 30 | 20 | 10 |
| Anticoagulation contraindicated, received mechanical prophylaxis | 4 | 4 | 0 |
| Missed opportunities for prevention | 29 | 23 | 6 |
| Percent (95% confidence interval) | 45 (32‐58) | 49 (30‐68) | 35 (12‐58) |
Anticoagulants used at teaching hospitals included heparin (15 cases), enoxaparin (4), and warfarin (1), while at nonteaching hospitals enoxaparin (7) and heparin (3) were used.
Each of the 10 patients who received no anticoagulation had the VTE risk factor of recent immobility prior to PE. Nine of the 10 had active malignancies, and 4 of these had undergone recent surgery. None had evidence of hypercoagulable states (factor V Leiden, lupus anticoagulant, or anticardiolipin antibodies). Five of the 10 patients died in the year following pulmonary embolism, 3 prior to discharge or within 2 weeks of discharge.
Missed Opportunities for Prevention
Among the 66 patients whose hospitalizations were characterized as missed opportunities for prevention, 30 received no pharmacologic VTE prevention despite having no contraindications. Seven patients had contraindications to pharmacologic prophylaxis, but none of these patients had contraindications to mechanical prophylaxis. An additional 18 patients received mechanical prophylaxis only despite having no contraindications to anticoagulation. Eleven patients received inadequate heparin regimens with or without mechanical prophylaxis (Table 3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| Number of patients | 66 | 43 | 23 |
| No contraindications, no prophylaxis | 30 | 18 | 12 |
| Anticoagulation contraindicated, no mechanical prophylaxis | 7 | 3 | 4 |
| No contraindication to anticoagulation, mechanical prophylaxis only | 18 | 13 | 5 |
| Inadequate heparin regimen, no mechanical prophylaxis | 9 | 7 | 2 |
| Inadequate heparin regimen, mechanical prophylaxis | 2 | 2 | 0 |
Discussion
Based on a random sample of 4963 elderly heart failure patients admitted to VA hospitals during a 1‐year period, we estimated that 63% received recommended interventions aimed at preventing VTE. Although differences in methodology limit comparisons with published reports, this rate is similar to those observed at individual hospitals,1113 in large multicenter registries of patients with DVT or at risk for VTE,14, 15 and in a recent multinational cross‐sectional study.16 Notably, chronic outpatient anticoagulation that was continued during hospitalization accounted for nearly one‐half of patients receiving preventive care. Compliance did not differ between teaching and nonteaching hospitals.
In a complementary approach to examining the extent of preventive care, we identified 1448 patients discharged with a diagnosis of PE. Most of these patients were excluded because they did not have a new event while hospitalized. Eleven (17%) of the 64 patients with confirmed in‐hospital PE received no preventive care before the event. An additional 18 (28%) received suboptimal heparin regimens or mechanical prophylaxis in the absence of contraindications to anticoagulation. As with the patients at risk for VTE, patients with established PE at teaching and nonteaching hospitals received similar rates of preventive care. Contrary to our expectation, the observed difference in rates between types of hospitals favored nonteaching hospitals. However, the sample size for this comparison was small and the difference did not reach statistical significance.
This study's population‐based approach permits conclusions about the performance of the VA's entire system of acute care hospitals. The results indicate that proven preventive therapies are often neglected at VA hospitals, but overall performance is probably comparable to other settings. VA employs an extensively implemented electronic medical record (EMR) and superior performance might have been expected. However, these results suggest limitations in the EMR as it is currently deployed. Successful efforts probably require a multifaceted approach incorporating decision support and institutional standardization.17
Several additional findings warrant comment. Patients with malignancies accounted for 9 of 10 patients who had PE after receiving no prior anticoagulation. Recent surgery was also a contributing factor for 4 of these cancer patients. Although both cancer and surgery are well‐known risk VTE factors, clinicians may not appreciate the extremely high risk associated with the combination.18 Particular effort may be warranted to ensure prophylaxis in this group, and more intensive measures may be necessary.
These results reveal several barriers to the accurate retrospective measurement of preventable inpatient PE. First, the use of discharge diagnoses to monitor the occurrence of inpatient PE is fraught with hazard. In this study, even after excluding patients with a discharge diagnostic code indicating a past history of PE, very few identified patients in fact had an acute or recent event. In addition, many patients were clearly admitted after having the onset of symptoms as outpatients. Further, reliance on discharge diagnoses alone can lead to the inclusion of patients with a presumptive diagnosis made without the advantage of imaging studies or postmortem examination. Although we overcame these barriers through careful record review and strict diagnostic criteria, our results suggest that efficient performance improvement efforts may require ongoing concurrent review.
There are several limitations of this study. First, we excluded PE patients whose diagnoses were made before the third hospital day. Some of these patients may have had events attributable to recent prior hospitalizations and should have received VTE prophylaxis. Second, we considered preventive measures applied at least 24 hours prior to PE to be acceptable evidence of prevention, potentially neglecting prior periods without treatment that might confer increased risk. Bias due to either of these limitations could exaggerate the compliance rates we report. Finally, the retrospective design of this study did not allow for consistent assessments of whether patients had the risk factor of immobility. Nevertheless, immobility was obvious for the 10 patients with PE who had no prior anticoagulation, all of whom had 2 or more risk factors.
Despite an acknowledged need for improvements in clinical practice, past efforts have had mixed results. For instance, in 1 study at a hospital with a well‐established EMR, computer alerts led to substantial improvement in the use of preventive measures and in VTE outcomes, but overall compliance remained low.19 On the other hand, a multidisciplinary approach can achieve marked reductions in preventable VTE events.20 Key elements of such an approach are a simplified risk assessment tool and concurrent monitoring of patient treatments and outcomes. The Agency for Healthcare Research and Quality has recently published a guide that outlines strategies for achieving breakthrough levels of improvement in the prevention of VTE.21
In conclusion, this population‐based study of hospitalized veterans with PE or at risk for VTE found compliance comparable to rates in published reports. Missed opportunities for prevention included inappropriate and inadequate interventions. Using discharge diagnoses to monitor the occurrence of inpatient PE is of limited value, and efficient performance improvement efforts may require ongoing concurrent review.
Acknowledgements
The authors thank Greg Maynard, MD, MS for advice on study design, and Deborah Howard, RN, for assistance with medical record review.
Pulmonary embolism (PE) is the most common preventable cause of death in hospitals,1 accounting for approximately 10% of hospital deaths. Most cases of PE result from dislodged lower extremity thrombi, so that deep vein thrombosis (DVT) and PE are manifestations of the same disorder, venous thromboembolism (VTE). Even though the majority of hospitalized patients are at increased risk for VTE and proven preventive measures have long been available, most patients do not receive appropriate care.2
Recent surgery is a well‐recognized risk factor for VTE, and surgeons have prescribed prophylactic therapies more consistently than other specialists.3 At the same time, prevention of VTE among hospitalized medical patients has been neglected.4 The American College of Chest Physicians recommends pharmacologic VTE prevention for most acutely ill medical patients, and advises prevention using mechanical devices when pharmacologic intervention is contraindicated.1
In Department of Veterans Affairs (VA) hospitals, compliance with preventive guidelines in surgical patients has been high. During October through December 2007, according to the Office of Quality and Performance, Veterans Health Administration, the national average for administration of VTE prophylaxis within 24 hours of surgery in VA hospitals was 92%. No comparable systemwide performance measure has been applied for medical patients, but an assessment involving intensive care unit patients has been completed and plans are underway for an evaluation of anticoagulant use among all inpatients considered to be at increased risk.
We sought to determine the extent to which hospitalized VA medical patients receive VTE preventive care in accordance with evidence‐based recommendations. Because quality of care may vary in hospitals based on teaching status,5 a secondary goal was to ascertain whether teaching and nonteaching facilities differ with respect to the delivery of care for VTE prevention.
Patient Populations Methods
We examined compliance with accepted VTE clinical practice guidelines in 2 patient populations. First, the care of patients at risk for developing VTE was evaluated for evidence of appropriate preventive measures. Second, the care of patients who developed PE while hospitalized was evaluated for evidence of preventive therapy prior to the event.
We identified patients discharged from VA acute care hospitals during the period April 1, 2006 to March 31, 2007, excluding patients hospitalized for less than 48 hours. We also excluded hospitalizations of VA patients at military and private hospitals because oversight of the quality of care provided at those facilities is beyond the purview of the Inspector General.
We then defined 2 distinct populations:
Medical patients at increased risk for VTE. These patients were identified by: (1) age 75 years at the time of admission; and (2) hospitalization with a principal discharge diagnosis of heart failure (International Classification of Diseases, 9th edition [ICD‐9] code 428). Elderly heart failure patients were chosen because advanced age and heart failure are recognized VTE risk factors, medical inpatients have been identified as being neglected in hospital VTE prevention efforts, and the VA was conducting no systemwide assessment of this aspect of care.
Patients with established PE. These patients had any discharge diagnosis pulmonary embolism and infarction (ICD‐9 codes 415.1 or 415.19), but those with the diagnostic code personal history of venous thrombosis and embolism (V12.51) were excluded.
Within each population, the discharge date defined an index hospitalization for evaluation. For patients discharged more than once with a qualifying diagnosis during the study period, we analyzed only the most recent hospitalization.
Characterization of Facilities
Hospitals were considered teaching hospitals if they were members of the Association of American Medical Colleges' Council of Teaching Hospitals and Health Systems (COTH).6 When COTH membership was through a Veterans Integrated Service Network, hospitals were judged to be teaching hospitals if they had 1 or more close university affiliations and/or management of medical inpatients by house staff.
Patient Selection and Medical Record Review
In order to ensure optimal representation of teaching and nonteaching hospitals, we stratified patients with increased VTE risk and those with diagnosed PE according to hospital teaching status, thereby creating 4 groups:
Patients at increased risk for VTEteaching hospitals;
Patients at increased risk for VTEnonteaching hospitals;
PE patientsteaching hospitals;
PE patientsnonteaching hospitals.
Within each group we assigned a random number to each patient, ordered the patients by random number, and selected patients sequentially until 50 patients were identified or no further eligible patients were available. For the heart failure patients, we assumed that all were at risk for VTE and required prophylaxis. For the group of patients with established PE, we excluded patients if the diagnosis was made prior to admission or in the first 2 hospital days, if there were no acute signs and symptoms and the diagnosis was chronic PE, or if there were no imaging studies or postmortem findings in support of the diagnosis.
In both groups, we assessed patients' records for VTE risk factors, evidence of preventive care, and contraindications.7 We considered pertinent VTE risk factors to be those included with published guidelines.1 In the care of patients with established PE, designation of adequate prophylactic therapy required at least 24 hours of treatment prior to diagnosis.
Appropriate VTE prophylaxis was defined as anticoagulant medications or, in the case of contraindications to anticoagulation, mechanical compression devices applied to the lower extremities with or without antiembolism stockings. Any administration of warfarin, lowmolecular‐weight heparin, or heparin by infusion, was considered adequate. Prophylaxis with subcutaneous unfractionated heparin was considered adequate only if at least 5000 units was administered 3 times daily.8 Aspirin and other antiplatelet agents were not considered to be anticoagulants.
We characterized hospitalizations of at‐risk individuals as missed opportunities for prevention if there were no contraindications to treatment and no evidence that adequate prophylactic therapy was provided.
Data Analysis
To determine sample size for each of the 2 study populations, we assumed the baseline rate of compliance with recommendations for VTE prophylaxis among medical inpatients to be 0.4 to 0.5.4 We further assumed that an observed compliance rate of 0.7 would be indicative of an important difference compared with published results (rate difference, 0.2‐0.3). With a Type 1 (alpha) error of 0.025 (1‐tailed), approximately 90 patients are required for a 0.9 probability of detecting a difference of at least 0.25.9
Comparisons between teaching and nonteaching hospitals were analyzed using chi‐square tests. Confidence intervals for estimates of overall compliance were calculated using a normal approximation to the binomial distribution.10
Results
Medical Patients at Increased Risk for VTE
We identified 4963 patients age 75 and older discharged after at least 2 days of acute hospitalization for heart failure: 3437 from 73 teaching hospitals and 1526 from 58 nonteaching hospitals. The 100 patients randomly selected for review ranged in age from 75 to 94 (median, 82) and had hospitalizations of 3 to 41 days (median, 6). Ninety‐eight were male. In this group of patients, we found 63 with evidence of adequate pharmacologic VTE prevention and 37 for which opportunities for prevention were not realized. At teaching hospitals, anticoagulation was effected with warfarin (13 cases), heparin (11), and enoxaparin (10). At nonteaching hospitals anticoagulants included warfarin (16), enoxaparin (11), and heparin (2). Twenty‐nine of the 63 patients who received anticoagulation (46%) were admitted while taking warfarin for chronic conditions. Teaching and nonteaching hospitals did not differ with respect to missed opportunities for prevention of VTE (37% in each group; Table 1).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 4963 | 3437 | 1526 |
| Randomly selected patients at risk | 100 | 54 | 46 |
| Received prophylactic anticoagulation | 63 | 34 | 29 |
| Missed opportunities for prevention | 37 | 20 | 17 |
| Percent (95% confidence interval) | 37 (27‐47) | 37 (23‐51) | 37 (22‐52) |
Patients With Established PE
We identified 1448 acute hospitalizations of at least 2 days duration for patients with PE, 1118 from 72 teaching hospitals and 330 from 51 nonteaching hospitals. We reviewed 779 medical records, 449 (40.2%) teaching cases and all 330 nonteaching cases. Chart review was completed after all nonteaching cases had been reviewed. In only 8.2% (64) of reviewed cases was the diagnosis of acute PE made after the first 2 hospital days and with accompanying objective evidence of VTE. Most cases (698; 89.6%) were excluded because there was only a remote history of PE or the diagnosis was made prior to admission. Additional cases (17; 2.2%) were excluded because the diagnosis was made during the first 2 hospital days; there were no acute signs and symptoms and the diagnosis was chronic PE; or there was no confirmation by computed tomography or ventilation‐perfusion scans, lower extremity ultrasonography in the setting of consistent clinical findings, or autopsy.
The 64 patients with confirmed in‐hospital PE ranged in age from 44 to 85 years (median, 65) and had hospitalizations of 4 to 53 days (median, 16). Sixty‐three were male. One of these patients had no definite risk factors for VTE and was ambulatory when acute symptoms occurred. Among the 63 patients who had unequivocal VTE risk factors, 34 (54%) received appropriate prophylactic treatment, and 29 (46%) received inadequate or no preventive therapy (Table 2). There was no significant difference between teaching and nonteaching hospitals with respect to missed opportunities for prevention (49% vs. 35%; P 0.3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| |||
| Number of patients | 1448 | 1118 | 330 |
| Randomly selected patients | 779 | 449 | 330 |
| Documented in‐hospital pulmonary embolism | 64 | 47 | 17 |
| No definite VTE risk factors | 1 | 0 | 1 |
| Received prophylactic anticoagulation | 30 | 20 | 10 |
| Anticoagulation contraindicated, received mechanical prophylaxis | 4 | 4 | 0 |
| Missed opportunities for prevention | 29 | 23 | 6 |
| Percent (95% confidence interval) | 45 (32‐58) | 49 (30‐68) | 35 (12‐58) |
Anticoagulants used at teaching hospitals included heparin (15 cases), enoxaparin (4), and warfarin (1), while at nonteaching hospitals enoxaparin (7) and heparin (3) were used.
Each of the 10 patients who received no anticoagulation had the VTE risk factor of recent immobility prior to PE. Nine of the 10 had active malignancies, and 4 of these had undergone recent surgery. None had evidence of hypercoagulable states (factor V Leiden, lupus anticoagulant, or anticardiolipin antibodies). Five of the 10 patients died in the year following pulmonary embolism, 3 prior to discharge or within 2 weeks of discharge.
Missed Opportunities for Prevention
Among the 66 patients whose hospitalizations were characterized as missed opportunities for prevention, 30 received no pharmacologic VTE prevention despite having no contraindications. Seven patients had contraindications to pharmacologic prophylaxis, but none of these patients had contraindications to mechanical prophylaxis. An additional 18 patients received mechanical prophylaxis only despite having no contraindications to anticoagulation. Eleven patients received inadequate heparin regimens with or without mechanical prophylaxis (Table 3).
| Hospital Type | |||
|---|---|---|---|
| Total | Teaching | Nonteaching | |
| Number of patients | 66 | 43 | 23 |
| No contraindications, no prophylaxis | 30 | 18 | 12 |
| Anticoagulation contraindicated, no mechanical prophylaxis | 7 | 3 | 4 |
| No contraindication to anticoagulation, mechanical prophylaxis only | 18 | 13 | 5 |
| Inadequate heparin regimen, no mechanical prophylaxis | 9 | 7 | 2 |
| Inadequate heparin regimen, mechanical prophylaxis | 2 | 2 | 0 |
Discussion
Based on a random sample of 4963 elderly heart failure patients admitted to VA hospitals during a 1‐year period, we estimated that 63% received recommended interventions aimed at preventing VTE. Although differences in methodology limit comparisons with published reports, this rate is similar to those observed at individual hospitals,1113 in large multicenter registries of patients with DVT or at risk for VTE,14, 15 and in a recent multinational cross‐sectional study.16 Notably, chronic outpatient anticoagulation that was continued during hospitalization accounted for nearly one‐half of patients receiving preventive care. Compliance did not differ between teaching and nonteaching hospitals.
In a complementary approach to examining the extent of preventive care, we identified 1448 patients discharged with a diagnosis of PE. Most of these patients were excluded because they did not have a new event while hospitalized. Eleven (17%) of the 64 patients with confirmed in‐hospital PE received no preventive care before the event. An additional 18 (28%) received suboptimal heparin regimens or mechanical prophylaxis in the absence of contraindications to anticoagulation. As with the patients at risk for VTE, patients with established PE at teaching and nonteaching hospitals received similar rates of preventive care. Contrary to our expectation, the observed difference in rates between types of hospitals favored nonteaching hospitals. However, the sample size for this comparison was small and the difference did not reach statistical significance.
This study's population‐based approach permits conclusions about the performance of the VA's entire system of acute care hospitals. The results indicate that proven preventive therapies are often neglected at VA hospitals, but overall performance is probably comparable to other settings. VA employs an extensively implemented electronic medical record (EMR) and superior performance might have been expected. However, these results suggest limitations in the EMR as it is currently deployed. Successful efforts probably require a multifaceted approach incorporating decision support and institutional standardization.17
Several additional findings warrant comment. Patients with malignancies accounted for 9 of 10 patients who had PE after receiving no prior anticoagulation. Recent surgery was also a contributing factor for 4 of these cancer patients. Although both cancer and surgery are well‐known risk VTE factors, clinicians may not appreciate the extremely high risk associated with the combination.18 Particular effort may be warranted to ensure prophylaxis in this group, and more intensive measures may be necessary.
These results reveal several barriers to the accurate retrospective measurement of preventable inpatient PE. First, the use of discharge diagnoses to monitor the occurrence of inpatient PE is fraught with hazard. In this study, even after excluding patients with a discharge diagnostic code indicating a past history of PE, very few identified patients in fact had an acute or recent event. In addition, many patients were clearly admitted after having the onset of symptoms as outpatients. Further, reliance on discharge diagnoses alone can lead to the inclusion of patients with a presumptive diagnosis made without the advantage of imaging studies or postmortem examination. Although we overcame these barriers through careful record review and strict diagnostic criteria, our results suggest that efficient performance improvement efforts may require ongoing concurrent review.
There are several limitations of this study. First, we excluded PE patients whose diagnoses were made before the third hospital day. Some of these patients may have had events attributable to recent prior hospitalizations and should have received VTE prophylaxis. Second, we considered preventive measures applied at least 24 hours prior to PE to be acceptable evidence of prevention, potentially neglecting prior periods without treatment that might confer increased risk. Bias due to either of these limitations could exaggerate the compliance rates we report. Finally, the retrospective design of this study did not allow for consistent assessments of whether patients had the risk factor of immobility. Nevertheless, immobility was obvious for the 10 patients with PE who had no prior anticoagulation, all of whom had 2 or more risk factors.
Despite an acknowledged need for improvements in clinical practice, past efforts have had mixed results. For instance, in 1 study at a hospital with a well‐established EMR, computer alerts led to substantial improvement in the use of preventive measures and in VTE outcomes, but overall compliance remained low.19 On the other hand, a multidisciplinary approach can achieve marked reductions in preventable VTE events.20 Key elements of such an approach are a simplified risk assessment tool and concurrent monitoring of patient treatments and outcomes. The Agency for Healthcare Research and Quality has recently published a guide that outlines strategies for achieving breakthrough levels of improvement in the prevention of VTE.21
In conclusion, this population‐based study of hospitalized veterans with PE or at risk for VTE found compliance comparable to rates in published reports. Missed opportunities for prevention included inappropriate and inadequate interventions. Using discharge diagnoses to monitor the occurrence of inpatient PE is of limited value, and efficient performance improvement efforts may require ongoing concurrent review.
Acknowledgements
The authors thank Greg Maynard, MD, MS for advice on study design, and Deborah Howard, RN, for assistance with medical record review.
- ,,.Prevention of venous thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest.2004;126:338S–400S.
- ,,,.Thromboprophylaxis rates in US medical centers: success or failure?J Thromb Haemost.2007;5:1610–1616.
- .Preventing venous thromboembolism in surgical patients.Cleve Clin J Med.2006;73:S88–S94.
- ,.Prevention of venous thromboembolism among hospitalized medical patients.Circulation.2005;111:e1–e3.
- ,,.Quality of care for the treatment of acute medical conditions in US hospitals.Arch Intern Med.2006;166:2511–2517.
- Association of American Medical Colleges (AAMC). Council of Teaching Hospitals and Health Systems (COTH). Available at: http://www.aamc. org/members/coth. Accessed August2009.
- Contraindications are those described in the Institute for Clinical Systems Improvement Health Care Guideline: Venous Thromboembolism Prophylaxis. 4th ed. June 2007, pp 13–14. Available at: http://www. icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/venous_thromboem bolism_prophylaxis/venous_thromboembolism_prophylaxis_5.html. Accessed August2009.
- ,,, et al.Prevention and treatment of venous thromboembolism. International Consensus Statement.Int Angiol.2006;25:101–161.
- ,.Designing Clinical Research.Baltimore, MD:Williams 1988.
- ,,. Statistical Methods for Rates and Proportions.3rd ed.Hoboken, NJ:Wiley‐Interscience;2003;28,54.
- ,,.New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment.Chest.2000;118;1680–1684.
- ,,.Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study.Pharmacotherapy.2006;26:1086–1090.
- ,,.Hospital‐acquired venous thromboembolism and prophylaxis in an integrated hospital delivery system.J Clin Pharm Ther.2006;31:455–459.
- ,;DVT FREE Steering Committee.A prospective study of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;15:259–262.
- ,,, et al.Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism.Chest.2007;132:936–945.
- ,,, et al.Venous thromboembolism risk and prophylaxis in the acute hospital care setting.Lancet.2008;371:387–394.
- .Medical admission order sets to improve deep vein thrombosis prevention: a model for others or a prescription for mediocrity?J Hosp Med.2009;4:77–80.
- ,,,,,.Prevention of venous thromboembolism in the cancer surgery patient.Cleve Clin J Med.2008;75(suppl 3):S17–S26.
- ,,, et al.Electronic alerts for hospitalized high‐VTE risk patients not receiving prophylaxis: a cohort study.J Thromb Thrombolysis.2008;25:146–150.
- ,,, et al. Prevention of hospital‐acquired venous thromboembolism: prospective validation of a VTE risk assessment model and protocol. Society of Hospital Medicine 2008 National Meeting. Electronic citation abstract #52, page 29. Available at: http://www.hospital medicine.org/Paperless2008/PDFs/Additional_Info/SHM08_Abstracts.pdf. Accessed August2009
- ,.Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ Publication No. 08–0075.Rockville, MD:Agency for Healthcare Research and Quality;2008.
- ,,.Prevention of venous thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest.2004;126:338S–400S.
- ,,,.Thromboprophylaxis rates in US medical centers: success or failure?J Thromb Haemost.2007;5:1610–1616.
- .Preventing venous thromboembolism in surgical patients.Cleve Clin J Med.2006;73:S88–S94.
- ,.Prevention of venous thromboembolism among hospitalized medical patients.Circulation.2005;111:e1–e3.
- ,,.Quality of care for the treatment of acute medical conditions in US hospitals.Arch Intern Med.2006;166:2511–2517.
- Association of American Medical Colleges (AAMC). Council of Teaching Hospitals and Health Systems (COTH). Available at: http://www.aamc. org/members/coth. Accessed August2009.
- Contraindications are those described in the Institute for Clinical Systems Improvement Health Care Guideline: Venous Thromboembolism Prophylaxis. 4th ed. June 2007, pp 13–14. Available at: http://www. icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/venous_thromboem bolism_prophylaxis/venous_thromboembolism_prophylaxis_5.html. Accessed August2009.
- ,,, et al.Prevention and treatment of venous thromboembolism. International Consensus Statement.Int Angiol.2006;25:101–161.
- ,.Designing Clinical Research.Baltimore, MD:Williams 1988.
- ,,. Statistical Methods for Rates and Proportions.3rd ed.Hoboken, NJ:Wiley‐Interscience;2003;28,54.
- ,,.New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment.Chest.2000;118;1680–1684.
- ,,.Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study.Pharmacotherapy.2006;26:1086–1090.
- ,,.Hospital‐acquired venous thromboembolism and prophylaxis in an integrated hospital delivery system.J Clin Pharm Ther.2006;31:455–459.
- ,;DVT FREE Steering Committee.A prospective study of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;15:259–262.
- ,,, et al.Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism.Chest.2007;132:936–945.
- ,,, et al.Venous thromboembolism risk and prophylaxis in the acute hospital care setting.Lancet.2008;371:387–394.
- .Medical admission order sets to improve deep vein thrombosis prevention: a model for others or a prescription for mediocrity?J Hosp Med.2009;4:77–80.
- ,,,,,.Prevention of venous thromboembolism in the cancer surgery patient.Cleve Clin J Med.2008;75(suppl 3):S17–S26.
- ,,, et al.Electronic alerts for hospitalized high‐VTE risk patients not receiving prophylaxis: a cohort study.J Thromb Thrombolysis.2008;25:146–150.
- ,,, et al. Prevention of hospital‐acquired venous thromboembolism: prospective validation of a VTE risk assessment model and protocol. Society of Hospital Medicine 2008 National Meeting. Electronic citation abstract #52, page 29. Available at: http://www.hospital medicine.org/Paperless2008/PDFs/Additional_Info/SHM08_Abstracts.pdf. Accessed August2009
- ,.Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ Publication No. 08–0075.Rockville, MD:Agency for Healthcare Research and Quality;2008.
Copyright © 2010 Society of Hospital Medicine
ONLINE EXCLUSIVE: Audio interview with Janet Corrigan, PhD, MBA
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file
Dr. Corrigan notes there are abundant examples of guideline adherence boosting quality outcomes, length of stay, and time to clinical stability.
Click here to listen to the audio file
Practical Neuroscience for Primary Care Physicians: Spring Issue
A supplement to Internal Medicine News.
TOPIC HIGHLIGHTS/FACULTY
Welcome Letter:
From the Publisher
Special Populations in Depression: Recognizing and Managing Depression in Women
Larry Culpepper, MD, MPH, Guest Editor
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc, Pfizer Inc, and Wyeth.
Case Files on Depression/Insomnia and Chronic Pain/Anxiety/Insomnia
Joseph A. Lieberman III, MD, MPH
Associate Professor of Medicine
Associate Editor, Delaware Medical Journal
Professor of Family Medicine
Jefferson Medical College of Philadelphia
Hockessin, Del.
Management of Disabling Migraine Episodes
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Boston, Mass.
Dr Bernstein has nothing to disclose.
Resources in the Spotlight
Point of View: Challenges in Primary Care Persist Over Time
William Clay Jackson, MD, DipTh
Family Medicine and Palliative Medicine
Memphis, Tenn.
Dr Jackson has received funding for clinical grants from Eli Lilly and Company. He is a consultant to AstraZeneca and Eli Lilly.
Practical Bits: Diagnostic Tools
A supplement to Internal Medicine News.
TOPIC HIGHLIGHTS/FACULTY
Welcome Letter:
From the Publisher
Special Populations in Depression: Recognizing and Managing Depression in Women
Larry Culpepper, MD, MPH, Guest Editor
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc, Pfizer Inc, and Wyeth.
Case Files on Depression/Insomnia and Chronic Pain/Anxiety/Insomnia
Joseph A. Lieberman III, MD, MPH
Associate Professor of Medicine
Associate Editor, Delaware Medical Journal
Professor of Family Medicine
Jefferson Medical College of Philadelphia
Hockessin, Del.
Management of Disabling Migraine Episodes
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Boston, Mass.
Dr Bernstein has nothing to disclose.
Resources in the Spotlight
Point of View: Challenges in Primary Care Persist Over Time
William Clay Jackson, MD, DipTh
Family Medicine and Palliative Medicine
Memphis, Tenn.
Dr Jackson has received funding for clinical grants from Eli Lilly and Company. He is a consultant to AstraZeneca and Eli Lilly.
Practical Bits: Diagnostic Tools
A supplement to Internal Medicine News.
TOPIC HIGHLIGHTS/FACULTY
Welcome Letter:
From the Publisher
Special Populations in Depression: Recognizing and Managing Depression in Women
Larry Culpepper, MD, MPH, Guest Editor
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc, Pfizer Inc, and Wyeth.
Case Files on Depression/Insomnia and Chronic Pain/Anxiety/Insomnia
Joseph A. Lieberman III, MD, MPH
Associate Professor of Medicine
Associate Editor, Delaware Medical Journal
Professor of Family Medicine
Jefferson Medical College of Philadelphia
Hockessin, Del.
Management of Disabling Migraine Episodes
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Boston, Mass.
Dr Bernstein has nothing to disclose.
Resources in the Spotlight
Point of View: Challenges in Primary Care Persist Over Time
William Clay Jackson, MD, DipTh
Family Medicine and Palliative Medicine
Memphis, Tenn.
Dr Jackson has received funding for clinical grants from Eli Lilly and Company. He is a consultant to AstraZeneca and Eli Lilly.
Practical Bits: Diagnostic Tools
ONLINE EXCLUSIVE: Audio interview with Roberta Fruth, PhD, RN, FAAN, JCR/JCI
Dr. Fruth suggests implementing standardized patient discharge education checklists, and says hospitalists "have been leading many workflow improvement projects."
Dr. Fruth suggests implementing standardized patient discharge education checklists, and says hospitalists "have been leading many workflow improvement projects."
Dr. Fruth suggests implementing standardized patient discharge education checklists, and says hospitalists "have been leading many workflow improvement projects."
ONLINE EXCLUSIVE: Evidence-Based Medicine Curveball
Even simple practice guidelines can be controversial. Guidelines are not created or implemented in a vacuum; they must be interpreted within a complex—and sometimes conflicting—milieu of medical, social, economic, and political forces.
This past November the U.S. Preventive Services Task Force, a federally funded, scientific advisory panel, released a 2009 update to its 2002 recommendations on breast cancer screening. The updated guideline said women in their 40s with an average risk for breast cancer do not need annual mammograms to screen for the disease, and older women at average risk of developing breast cancer need screening only once every two years.
The new guideline sparked disagreement among physicians, and a heated political debate as to whether the recommendation amounted to government-mandated, guideline-based, economically motivated healthcare rationing.
Some groups, including the American Cancer Society, said that mammograms have been proven to save lives by spotting tumors early on when they are most easily treated, and said they would stick by their current guideline to start annual mammogram screening at age 40. The Radiological Society of North America cited studies showing mammography of women in their 40s saves lives, and said about 20% of all breast cancer deaths in our country occur in women in their 40s.
The timing of the task force's recommendation was unfortunate (some lawmakers said it was calculated), as it was announced in the midst of the heated congressional healthcare reform debate. Although the new guideline would save a portion of the more than $5 billion spent on mammography in the U.S. each year, the task force said politics played no part in its recommendation, and that cost savings were never considered in its discussions. The task force acknowledged potential benefits of earlier testing, but attempted to balance those benefits with the potential harms of unnecessary radiation exposure, biopsies, overdiagnosis and overtreatment, and anxiety to women who get false positive results, which the panel said occurs in 10 percent of mammograms.
Even simple practice guidelines can be controversial. Guidelines are not created or implemented in a vacuum; they must be interpreted within a complex—and sometimes conflicting—milieu of medical, social, economic, and political forces.
This past November the U.S. Preventive Services Task Force, a federally funded, scientific advisory panel, released a 2009 update to its 2002 recommendations on breast cancer screening. The updated guideline said women in their 40s with an average risk for breast cancer do not need annual mammograms to screen for the disease, and older women at average risk of developing breast cancer need screening only once every two years.
The new guideline sparked disagreement among physicians, and a heated political debate as to whether the recommendation amounted to government-mandated, guideline-based, economically motivated healthcare rationing.
Some groups, including the American Cancer Society, said that mammograms have been proven to save lives by spotting tumors early on when they are most easily treated, and said they would stick by their current guideline to start annual mammogram screening at age 40. The Radiological Society of North America cited studies showing mammography of women in their 40s saves lives, and said about 20% of all breast cancer deaths in our country occur in women in their 40s.
The timing of the task force's recommendation was unfortunate (some lawmakers said it was calculated), as it was announced in the midst of the heated congressional healthcare reform debate. Although the new guideline would save a portion of the more than $5 billion spent on mammography in the U.S. each year, the task force said politics played no part in its recommendation, and that cost savings were never considered in its discussions. The task force acknowledged potential benefits of earlier testing, but attempted to balance those benefits with the potential harms of unnecessary radiation exposure, biopsies, overdiagnosis and overtreatment, and anxiety to women who get false positive results, which the panel said occurs in 10 percent of mammograms.
Even simple practice guidelines can be controversial. Guidelines are not created or implemented in a vacuum; they must be interpreted within a complex—and sometimes conflicting—milieu of medical, social, economic, and political forces.
This past November the U.S. Preventive Services Task Force, a federally funded, scientific advisory panel, released a 2009 update to its 2002 recommendations on breast cancer screening. The updated guideline said women in their 40s with an average risk for breast cancer do not need annual mammograms to screen for the disease, and older women at average risk of developing breast cancer need screening only once every two years.
The new guideline sparked disagreement among physicians, and a heated political debate as to whether the recommendation amounted to government-mandated, guideline-based, economically motivated healthcare rationing.
Some groups, including the American Cancer Society, said that mammograms have been proven to save lives by spotting tumors early on when they are most easily treated, and said they would stick by their current guideline to start annual mammogram screening at age 40. The Radiological Society of North America cited studies showing mammography of women in their 40s saves lives, and said about 20% of all breast cancer deaths in our country occur in women in their 40s.
The timing of the task force's recommendation was unfortunate (some lawmakers said it was calculated), as it was announced in the midst of the heated congressional healthcare reform debate. Although the new guideline would save a portion of the more than $5 billion spent on mammography in the U.S. each year, the task force said politics played no part in its recommendation, and that cost savings were never considered in its discussions. The task force acknowledged potential benefits of earlier testing, but attempted to balance those benefits with the potential harms of unnecessary radiation exposure, biopsies, overdiagnosis and overtreatment, and anxiety to women who get false positive results, which the panel said occurs in 10 percent of mammograms.
Flu Season, Part Deux
The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.
The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.
“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”
Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.
“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”
The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.
The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.
“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”
Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.
“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”
The public, physician, and media fascination with the H1N1 pandemic can serve as a healthy reminder this winter for hospitalists not to overlook seasonal influenza.
The attention focused on H1N1 influenza prompted the early release by the Journal of the American Medicine Association (JAMA. 2010;303[1]:doi10.1010/JAMA.2009.1911) of a study on the effectiveness of the virus’ vaccine. The attention also has prompted many hospitals to create processes for hospitalists and other staff to communicate with primary-care physicians (PCPs), community clinicians, and local health departments, according to Rick Hilger, MD, FHM, director of resident education of hospital medicine, and medical director of care management at Regions Hospital in Saint Paul, Minn. In particular, the attention on H1N1 has helped develop “open lines of communication” with infectious-disease doctors who often are the initial stop for influenza cases, Dr. Hilger says.
“When H1N1 was peaking this fall, we were getting probably biweekly e-mail updates as to what they were seeing in the community and them making recommendations,” says Dr. Hilger, who is also an assistant professor of medicine at the University of Minnesota. “I think we were spoiled in that respect. I would highly recommend that all hospitalists try to speak with … their local infectious-disease doctors to see what’s out there this winter.”
Dr. Hilger suggests hospitalists use the focus on influenza this winter to redouble efforts to vaccinate at-risk populations and work with infectious-disease specialists when patients are admitted with clinical signs of infection. He adds that hospitalists, as front-line staffers at small and community hospitals, should be used to dealing with seasonal influenza.
“I don’t think that seasonal influenza will be a sleeper problem, in general,” Dr. Hilger says. “We all have a lot of experience with it. If anything, H1N1 will increase our awareness of it because we can’t go a day without influenza activity being talked about, whether it’s within our hospitalist group or whether it’s in administration.”
Hospital Mortality Rates Improve, but Quality Gap Persists
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Risk-adjusted mortality and complication rates have decreased nearly 11% from 2006 through 2008, according to the12th annual HealthGrades Quality in America Study. However, the report found a wide gap between the nation’s best hospitals and all others. To save thousands of lives, the authors suggested focused improvement in sepsis, pneumonia, heart failure, and respiratory failure.
The report showed patients at highly rated hospitals have a 52% lower chance of dying, compared with the U.S. hospital average, according to the study authors. The rankings used 40 million Medicare patient outcomes from 2006 to 2008, and analyzed more than 5,000 U.S. hospitals. The scoring was based on 30 common procedures and diagnoses.
Patrick Torcson, MD, FHM, chair of SHM’s Performance and Standards Committee, says hospitalists may be one reason highly rated hospitals did well. “We’re on-site to evaluate patients and facilitate transition of care,” Dr. Torcson says. “I think that’s where the biggest impact is going to be.”
At Christ Hospital in Cincinnati, one of the nation’s top performers, hospitalist Rajan Lakhia, DO, credits the “absolute attitude everyone around here has—a dedication to quality.”
Berc Gawne, MD, the hospital’s chief medical officer, agreed. “Hospitalists know the people, policies, and politics. They know the barriers and where to go to get things done,” he says. “It’s their hospital and they take ownership for the order sets, the critical pathways, and performance improvement.”
Scottsdale Healthcare in Arizona has improved its ratings in recent years. Perhaps not coincidentally, the facility hired a hospitalist group two years ago to improve the quality of care. According to hospitalist Barry Freeman, MD, each quarter, the hospital publishes quality measures, and goals are established as part of a scorecard. Results are regularly reviewed and improvement discussed. In taking care of almost all medical and surgical patients, the hospitalists “can further educate the nonhospitalist staff on quality efforts and initiatives under way,” Dr. Freeman explains.
Clinical Update: Challenges in the Management of Constipation and Other Gastrointestinal Disorders
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
A supplement to Internal Medicine News.
This Clinical Update is supported by Braintree Laboratories, Inc.
The articles are based on interviews with the faculty.
To view the supplement, click the image above.
Topic Highlights
Gastrointestinal Disorders: When to Refer?
Understanding the Anatomy and Physiology of Constipation
Lawrence R. Schiller, MD, FACP, FACG
Program Director, Gastroenterology Fellowship
Department of Gastroenterology
Baylor University Medical Center
Dallas, TX
Consultant: Braintree Laboratories, Inc. and Novartis Pharmaceuticals. He discusses the unlabeled use of tegaserod for constipation. He also discusses the investigational use of NT-3 for constipation.
Management of Constipation Begins With Attention to Clinical Details
Jack A. DiPalma, MD, FACP, FACG
Professor and Director
Division of Gastroenterology
University of South Alabama College of Medicine
Mobile, AL
Grant/Research Support and Consultant: Braintree Laboratories, Inc.
Recent Clinical Trials Provide Stronger Basis for Constipation Therapy
Lawrence R. Schiller, MD, FACP, FACG
Patients at Opposite Ends of the Age Spectrum Share Clinical Features of Constipation
Jack A. DiPalma, MD, FACP, FACG
Surgical Treatment for Chronic Constipation: Favorable Option in Selected Patients
David E. Beck, MD, FACS
Chairman, Department of Colon and Rectal Surgery
Ochsner Clinical Foundation
New Orleans, LA
Nothing to disclose.
Recent H. pylori Literature Explores New Questions
Abuse Potential of Sleeping Agents: Liability Varies Among Agents
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
A supplement to Internal Medicine News.
This CLINICAL UPDATE is supported by Takeda Pharmaceuticals North America, Inc.
•Introduction
•Topic Highlights
To view the supplement, click the image above.
Introduction
Introduction
Roland R. Griffiths, PhD
Professor of Behavioral Biology
Departments of Psychiatry and Neuroscience
Johns Hopkins University
School of Medicine
Baltimore, Md.
Dr. Griffiths has disclosed that he is Principal Investigator of two grants from the National Institute on Drug Abuse (NIDA) (R01 DA03889 and R01 DA03890) and co-investigator on a contract and several other grants from NIDA. During the past 5 years, on issues about drug abuse liability, he has been a consultant to or received grants from the following pharmaceutical companies: Abbott Laboratories, Forest Laboratories Inc., Merck & Co., Inc., Neurocrine Biosciences, Inc., Novartis Pharmaceuticals Corporation, Orphan Medical, Pharmacia Corporation, Pfizer Inc., Takeda Pharmaceuticals, TransOral Pharmaceucticals, Inc., Somaxon Pharmaceuticals Inc., and Wyeth Pharmaceuticals. He has disclosed that he will be discussing non-medical use (ie, abuse) of various hypnotic drugs.
Topic Highlights
• Abuse Potential of Sleeping Agents: Liability Varies Among Agents
Insomnia: A Brief Review
Effects of Insomnia
Pharmacologic Treatment of Insomnia
Patterns of Sedative/Hypnotic Abuse
• Abuse Potential of Hypnotic Agents: Study Evaluates Relative Abuse Liability
Defining Relative Abuse Liability and Toxicity
Relative Abuse Liability Table
Results of Analysis
New Benchmarks in Acid-Related Disorders: A Debate With the Experts
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
A supplement to Internal Medicine News supported by a restricted grant from TAP Pharmaceutical Products, Inc.
Symposium Highlights of articles based on presentations given at a continuing medical education symposium held on May 19, 2002, in San Francisco, Calif.
To view the supplement, click the image above.
