Universal EHRs Clinical Decision Support for Thromboprophylaxis
- The use of clinical decision support to determine appropriate thromboprophylaxis for medically ill patients in the inpatient setting, and at discharge, increased the use of thromboprophylaxis.
- There were fewer venous, arterial, and total thromboembolisms in the intervention groups.
- Major bleeding was rare in both the intervention and usual care groups.
Does the use of a universal, platform-agnostic, electronic health record (EHR)-embedded venous thromboembolism (VTE) risk assessment model with integrated clinical decision support (CDS) increase rates of appropriate thromboprophylaxis and reduce thromboembolism compared to usual medical care?
This was a cluster randomized trial of four New York tertiary academic hospitals (two hospitals were in the intervention group [n = 11, 309] and two hospitals were in the control group [n = 8, 514]) that were selected based on historical admissions for medical illness diagnoses. Patients were enrolled consecutively upon admission to study hospitals from December 21, 2020, to January 21, 2022. Eligible inpatients were medically ill over the age of 60 years with a primary diagnosis of at least one of five medical illness categories and additional risk factors per the IMPROVE-DD VTE (International Medical Prevention Registry on Venous Thromboembolism plus D-Dimer) score. All patients were assumed to have had relative immobility for at least one day during hospitalization. Patients were excluded if they were on therapeutic anticoagulation prehospitalization or within 24 hours of admission and had a history of atrial fibrillation. All patients in the trial had an IMPROVE-DD VTE score of 2. The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included venous, arterial, and total thromboembolism; major bleeding; and all-cause mortality through 30 days post-discharge. Patients in the intervention group were also prescribed extended prophylaxis post-discharge.
After exclusions, 10,699 of 19,823 patients were analyzed. Intervention group tool adoption was 77.8%. Appropriate thromboprophylaxis was increased at intervention hospitals, both inpatient (80.1% vs. 72.5%, odds ratio [OR], 1.52; 95% confidence interval [CI], 1.39-1.67) and at discharge (13.6% vs. 7.5%, OR, 1.93; 95% CI, 1.60-2.33). There were fewer venous (2.7% vs. 3.3%, OR, 0.80; 95% CI, 0.64-1.00), arterial (0.25% vs. 0.70%, OR, 0.35; 95% CI, 0.19-0.67), and total thromboembolisms (2.9% vs. 4.0%, OR, 0.71; 95% CI, 0.58-0.88) at intervention hospitals. Major bleeding was rare and did not differ between groups. Mortality was higher at intervention hospitals (9.1% vs. 7.0%, OR, 1.32; 95% CI, 1.15-1.53).
This multicenter cluster randomized trial of hospitalized patients, including those with COVID-19, supported that universal, EHR-integrated CDS using a validated VTE risk assessment model could increase rates of appropriate thromboprophylaxis and reduce venous, arterial, and total thromboembolism without increasing major bleeding.
This cluster randomized controlled trial showed that a clinical decision support tool can reduce thromboembolisms. Even though the adoption rate was at 77.8%, patients who were identified as being high risk for VTE benefited from the intervention. EHRs can improve patient outcomes when the appropriate tools are available within the electronic system. Documenting within the EHR can be burdensome, but there is potential to use the information to improve patient outcomes.
Clinical Topics: Vascular Medicine
Keywords: Electronic Health Records, Hemorrhage, Inpatients, Risk Assessment, Thromboembolism
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