Background: Venous Thromboembolism (VTE) is a potentially life-threatening disorder and in some cases, is related to underlying hypercoagulability which may be congenital or acquired. Guidelines suggest performing extensive work -up for hypercoagulability only in select patients: those with close family history of VTE at young age ( < 45), young age at first VTE (<45), patients with recurrent thrombosis or thrombosis in unusual sites. Workups for hypercoagulable states are often either not indicated (in older patients, provoked VTE) or uninterpretable (if functional tests are ordered while patient anticoagulated or with active thrombus). Unnecessary hypercoagulable testing costs insurers and patients close to half a billion dollars yearly. We conducted a quality improvement study of a clinical decision support tool to reduce unnecessary and inappropriate testing.
Methods: Clinical decision support in the form of a new cascading order set was developed on the hospital’s Electronic Medical Records (EMR) for VTE admissions. A section of the order set provided evidenced-based guidance for ordering hypercoagulable work-up in real time by providing relevant prompts (age, provoked/unprovoked, active thrombus, anticoagulation) at the point of order entry. Tests were also grouped based on the prompts so that gene tests alone or gene tests and functional tests were auto-selected based on the response to the prompts. For measuring its effectiveness, hypercoagulable workups were defined as appropriate when ordered in patients who are < 45 years of age with unprovoked thrombus. In addition, functional tests had to be performed only in patients without active thrombi or anticoagulants. Tests that did not meet these criteria were deemed inappropriate. The order set was rolled out in April 2015, after extensive education of health care providers and the effects of intervention on appropriate test ordering were subsequently measured until May 2017. The 12 month period preceding the roll-out was used as the baseline year (pre-intervention). Our primary outcome measure was the average monthly number of patients with inappropriate work-ups and average cost savings per month was the secondary measure, using current costs of laboratory tests. All data was collected from reports generated on the Hospital EMR.
Results: Over the 2 years after the addition of the clinical decision support intervention, there was a reduction of the average number of patients with inappropriate hypercoagulable state work-ups from 33 per month ( pre-intervention) to 14 per month (post intervention) – a 57% reduction. Cost savings realized per month from the intervention was $4,500 per month on average (pre-intervention: $9,050.73, post-intervention $4,569.98; P – 0.0004) and totaled about $117,000 over 26 months post intervention.
Conclusions: Clinical decision support interventions may result in a sustained decrease in unnecessary hypercoagulable workups.
To cite this abstract:Abdulkareem, AO; Karmacharya, P; Pathak, R; Donato, AA. EFFECTIVENESS OF CLINICAL DECISION SUPPORT FOR REDUCING UNNECESSARY HYPERCOAGULABILITY EVALUATIONS IN A LARGE COMMUNITY HOSPITAL. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 203. https://www.shmabstracts.com/abstract/effectiveness-of-clinical-decision-support-for-reducing-unnecessary-hypercoagulability-evaluations-in-a-large-community-hospital/. Accessed January 18, 2020.