The Joint Commissions’ core measure on VTE prevention has added more pressure to increase the rate of VTE prophylaxis in hospitalized medical patients. One potential unintended consequence of this is an increase in the use of anticoagulant prophylaxis in patients at high risk of bleeding. We sought to find whether quality improvement efforts aimed at increasing VTE prophylaxis also increase the rate of anticoagulant prophylaxis in patients at high risk for bleeding and whether this is associated with increased in‐hospital bleeding rates. We used data from the Michigan Hospital Medicine Safety (HMS) Consortium.
Detailed demographic and clinical data of hospitalized medical patients from 40 collaborating hospitals were collected using web‐based data entry, including risk factors for VTE, use of pharmacologic prophylaxis, and VTE events out to 90 days after discharge. Patients who were < 18 years of age, pregnant, admitted for surgery or palliative care, admitted directly to the ICU, at low risk for VTE, or were prescribed therapeutic doses of an anticoagulant were excluded. Contraindications to pharmacologic prophylaxis as defined by the collaborative included high risk metastasis to the brain and/or presence of intracranial monitoring device, severe trauma to the head or spinal cord within the last 24 hours, gastrointestinal or genitourinary hemorrhage within the last 6 months, intracranial hemorrhage within the last year, other hemorrhage within the last 6 months, or platelets < 50,000/mm3. At risk for VTE was defined as a Caprini score > 2. Pharmacologic prophylaxis among at risk patients was tracked over time. Non‐parametric tests for trend across ordered groups were used to determine statistical significance of changes in pharmacologic prophylaxis and in major bleeding.
A total of 40,877 patients met inclusion criteria, of whom 64% had pharmacologic prophylaxis scheduled on admission and 14.3% had at least one contraindication to pharmacologic prophylaxis. While the rate of pharmacologic prophylaxis ordered on admission for at risk patients without contraindications increased by 29% (p< 0.001 for trend), it increased from 8.7% to 25.8% (p<0.001 for trend) in patients with contraindications. Major bleeding increased from 0.2% to 0.6% among all patients on pharmacologic prophylaxis (p= 0.052 for trend).
Quality improvement efforts that significantly increased the rate of pharmacologic prophylaxis in hospitalized medical patients also led to an unintended increase in the rate of pharmacologic prophylaxis in patients with contraindications to anticoagulants. This was associated with a trend toward an increase in major bleeding.
To cite this abstract:Kaatz S, Paje D, Lee B, Greene M, Bernstein S, Flanders S. Unintended Consequences of Increasing Pharmacologic Venous Thromboembolic Prophylaxis in Hospitalized Medical Patients. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 701. https://www.shmabstracts.com/abstract/unintended-consequences-of-increasing-pharmacologic-venous-thromboembolic-prophylaxis-in-hospitalized-medical-patients/. Accessed December 10, 2018.