Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 39-43

Effect of academic detailing on improvement in venous thromboembolism prophylaxis for critically ill and surgical patients in a tertiary care teaching hospital


1 Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
2 Department of Surgery, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India
3 Department of Critical Care, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India

Date of Submission10-Jun-2019
Date of Decision01-Jul-2019
Date of Acceptance31-Jul-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Bijoy Kumar Panda
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_35_19

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  Abstract 


Background: Routine utilization of venous thromboembolism (VTE) risk assessment tool and prophylaxis has been suggested to prevent morbidity and mortality caused due to hospitalized VTE. At our tertiary care teaching hospital, underutilization of VTE thromboprophylaxis was a concern. Aim: This prospective interventional study evaluated the effect of academic detailing on improvement in VTE prophylaxis after risk assessment for critically ill and surgical inpatients at an Indian tertiary care teaching hospital. Methods: A focused group academic detailing for medical practitioners was performed. After the assessment of VTE risk with the help of Caprini VTE risk assessment model, inpatients were monitored for thromboprophylaxis according to risk score. Utilization improvement was assessed by comparing with our published results of the historical preeducation control group. The main outcome measures were VTE risk assessment in hospitalized patients, proportion of prophylaxis in risk categories post education, comparison with findings of the preeducation historical comparison group to assess the improvement of thromboprophylaxis in intensive care unit (ICU), and surgical ward. Results: Thromboprophylaxis was adopted in 288 (56.4%) postacademic detailing as compared to 46 (35.2%) preacademic detailing in the historical control group. The overall prophylaxis for VTE improved significantly with an absolute difference of 21%. The positive impact of academic detailing was significantly observed in ICU compared to surgical ward for VTE prophylaxis. Fear of bleeding and unproven VTE in follow-up Doppler prospective studies in postsurgical patients were the reasons for underutilization. Conclusions: An improvement for VTE prophylaxis was observed in ICU compared to surgical ward. The overall prophylaxis for at-risk VTE inpatients also improved, particularly in higher and highest-risk inpatients.

Keywords: Academic detailing, critically ill, surgical patients, thromboprophylaxis, venous thromboembolism


How to cite this article:
Panda BK, Kumar V, Ketkar M N, Shah J. Effect of academic detailing on improvement in venous thromboembolism prophylaxis for critically ill and surgical patients in a tertiary care teaching hospital. Indian J Vasc Endovasc Surg 2020;7:39-43

How to cite this URL:
Panda BK, Kumar V, Ketkar M N, Shah J. Effect of academic detailing on improvement in venous thromboembolism prophylaxis for critically ill and surgical patients in a tertiary care teaching hospital. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Apr 8];7:39-43. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/39/280666




  Introduction Top


Venous thromboembolism (VTE) has been identified to be one of the common reasons for morbidity and mortality in critically ill patients, postsurgical patients, and elective major orthopedic surgeries.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] In developing countries, like India, VTE is not unusual, and the leading factors are cancer, general surgery,[15] and orthopedic surgery.[16] An Indian study identified pulmonary embolism in 1000 reviewed autopsy cases, where sepsis, hepatobiliary disease, cardiovascular disease, malignancy, and renal and endocrine disorders were the primary diagnosis.[17] The American College of Chest Physicians (ACCP)[18] currently recommends that every hospital should develop specific strategies for assessing VTE risk and also plan for the implementation of any appropriate prophylaxis. The ACCP currently recommends unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) for the prevention of VTE.[18] A consensus arrived on the current guideline recommendations for the routine use of postoperative thromboprophylaxis, which should be implemented in Asia, although the exact incidence of VTE in local populations requires confirmation in large, well-designed clinical trials.[19] There are several published studies which specify the underutilization of risk assessment tool and thromboprophylaxis in hospitalized patients.[20],[21],[22],[23],[24],[25],[26],[27],[28] These studies suggest routine utilization of risk assessment tool and prophylaxis to prevent morbidity and mortality caused due to hospitalized VTE.

A previous evaluation regarding the use of VTE prophylaxis at our tertiary care teaching hospital revealed the underutilization of VTE prophylaxis in critically ill intensive care unit (ICU) and postsurgical patients in surgical wards.[29] Pharmacological thromboprophylaxis to higher and highest VTE risk patients was low in ICU and very low in surgical ward. Efforts are required to improve patient safety practice, particularly in higher and highest-risk categories. The underutilization of VTE thromboprophylaxis practices at our institution prompted us to intervene for improvement in clinical practice. Multiple studies [30],[31],[32],[33],[34],[35] have proved that various active and passive interventions can bring improvement in the implementation of clinical practice guidelines for VTE thromboprophylaxis; hence, the present study was aimed to improve the quantity of VTE prophylaxis through a focus group discussion with the medical team members of ICU and surgical ward, thereby addressing the underutilization.


  Methods Top


Study design

A prospective interventional study (academic detailing and implementation of Caprini VTE Risk Assessment Model)[35] was conducted in the ICU and general surgical ward at Bharati Hospital and Research Center, a 900-bedded tertiary care teaching hospital in Pune, Maharashtra, India. Based on the underutilization reports of VTE prophylaxis found in the initial data collection (preeducation) period,[29] clinical pharmacist-driven academic detailing was initiated with the intent of improving the quantity of VTE prophylaxis in both the units. Patients in this initial data collection (preeducation) period served as the historical control (comparison) group.[29] A 1-day academic sensitization program was initiated in September 2014. This academic detailing imparted (one to group) educational presentations to all physicians, consultants, surgeons, postgraduate students, and residents of these two units. The academic contents which were detailed to them included attributes of Caprini Risk Assessment tool;[35] the method of calculation using risk factors; importance of range of score in predicting risk category; and type, dose, and duration of VTE prophylaxis in accordance to risk levels. They were all also informed about the underutilization of VTE prophylaxis in their respective units. The presentation and discussion focused on the following four main points: (1) hospitalized critical ill and surgical patients are at risk for developing VTE, (2) how to identify patients who require VTE prophylaxis, (3) the fact that VTE prophylaxis is currently underutilized in both unit's patients, and (4) appropriate VTE prophylaxis strategies according to ACCP recommendations. A nonprobabilistic sample was adopted as there were insufficient Indian studies on thromboprophylactic interventions.

Ethical approval

This study was approved by the institutional ethics committee (letter no. BVDU/MC/06 dated 02/09/2014).

Study population

All hospitalized patients aged more than 18 years admitted during September 2014–August 2016 were included in the study. Children, pregnant and lactating women, patients already on anticoagulant on admission, patients whose admitting diagnosis was any form of VTE, and patients with prosthetic heart valves were excluded from the study.

Data collection

A standard Caprini VTE Risk Assessment Model [35] was implemented by a clinical pharmacist to categorize risk levels. After the academic detailing, the clinical pharmacist started follow-up of patients in both the units. The demographic details such as age, sex, and other baseline information such as type of infection and surgery, date of admission and discharge, and diagnosis and risk factors for VTE were collected in a predesigned data collection form. All the patients were categorized into moderate, higher, and highest risk using the risk assessment model. The risk score and level were recorded on the patient's case sheet for communication with the prescriber for initiation of prophylaxis for VTE in accordance to the risk levels.

The proportion of patients receiving VTE prophylaxis according to patient's risk category was ascertained (mechanical and/or pharmacological thromboprophylaxis in moderate-, higher-, and highest-risk patients). Appropriate pharmacological thromboprophylaxis or VTE prophylaxis was defined as the selection of appropriate drug as recommended in ACCP guideline [18] for the diagnosed clinical or surgery condition.

The findings from the post education group were then compared with the findings of the preeducation historical comparison group [29] to assess the improvement of thromboprophylaxis in ICU and surgical ward. The results were disseminated to all the physicians and surgeons of the units in September 2016. A focus group discussion was conducted again to discuss the study outcomes and to find out possible barriers toward the VTE prophylaxis.

Outcome measures and data analysis

Continuous variables were described as mean ± standard deviation (SD) for normally distributed variables and categorical variables as percentages. To compare between categorical variables Chi-square test was used. Test for trends to compare proportions in two groups and ANOVA to compare means were adopted. A 5% level of significance was accepted for all statistical tests.


  Results Top


Of 1184 patients admitted to the hospital, 510 patients were included [Figure 1], of which 354 (69.4%) were in the ICU and 156 (30.5%) in surgical ward. The overall mean age (SD) of patients was 55.4 (14.1) years; a nonsignificant difference was found in the age groups of patients admitted in both the wards. Overall, 396 (77.6%) patients were male and the rest were female. [Table 1] illustrates the risk factors for the development of VTE where according to Caprini VTE risk assessment, 30 (5.8%) inpatients were classified as having moderate risk, 246 (48.2%) having higher, and 234 (45.8%) having the highest risk. The mean number of risk factors (SD) was 2 (0.7) in moderate-risk patients, 2.9 (0.4) in higher-risk patients, and 3.3 (0.9) in highest-risk patients (P < 0.001).
Figure 1: Flowchart of the study protocol

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Table 1: Risk categories of patients and prophylaxis according to the Caprini Venous Thromboembolism Risk Assessment Tool

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[Table 2] summarizes the VTE risk factor score and prophylaxis for VTE initiated in ICU and surgical wards. The mean number of risk factors of ICU patients was significantly lower compared to postsurgical patients (2.8 [0.6] vs. 3.5 [0.7]). Prophylaxis for VTE was used in 78.1% (150 out of 192) of higher and highest-risk patients admitted in the ICU, whereas only in 7.6% (12 out of 156) of higher and highest-risk patients admitted in surgical ward. Overall, VTE prophylaxis was implemented in 288 (56.5%) of the 510 enrolled patients in ICU and surgical ward. Out of the 288 patients who were on some form of VTE prophylaxis, 234 inpatients were prescribed with pharmacological prophylaxis. Implementation of VTE prophylaxis increased in ICU inpatients (276, 77.9%) post academic detailing compared to surgical inpatients (7.6%). Overall, appropriate pharmacological prophylaxis for VTE with LMWH was observed in 114 (39.5%) inpatients, whereas UFH in 120 (41.6%) inpatients. Out of the 288 patients, only 54 (42 active bleeding, 12 thrombocytopenia, 24.3%) inpatients had some contraindications, concerning to the use of LMWH and/or UFH. Nonpharmacological prophylaxis (mechanical prophylaxis) with elastic stockings was utilized in 6 out of the 54 (11%) patients who were contraindicated to pharmacological thromboprophylaxis.
Table 2: Risk factor and prophylaxis of venous thromboembolism in different wards

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The quantity of prophylaxis for VTE in ICU significantly increased from 46% to 76% (P = 0.001), whereas in surgical ward, a slight increase of 1% (6.6%–7.6%) was observed. The overall quantity of thromboprophylaxis was still low (288 of 510; 56.4%) post academic detailing, as shown in [Table 3].
Table 3: Demographic comparison and improvement in the quantity of pharmacological thromboprophylaxis pre- and post-academic detailing

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  Discussion Top


Various studies though retrospective have reported 30%–45% prophylaxis utilization rate in hospitals. However, few have conducted and documented programs for addressing the challenges of underutilization of prophylaxis for at-risk VTE. A recent study also stressed upon the implementation of VTE risk assessment in medically ill and surgical inpatients and adoption of various VTE prevention strategies.[36] Looking into all these facts, this study is unique in its kind in India as for the first time a clinical pharmacist has been involved in implementing the Caprini Risk Score for VTE risk assessment and conducting an academic detailing intervention to address the underutilization of prophylaxis of any kind for VTE. Our previous study identified moderately low and very low thromboprophylaxis in ICU and surgery ward respectively.[29] This motivated us to carry out an academic detailing intervention for the improvement in prescribing for VTE prophylaxis.

Our current and previous study [29] identified that more than 45% of hospitalized patients in ICU and surgical wards were at higher and highest risk for VTE, which shows the necessity of the use of thromboprophylaxis. This same proportion of hospitalized patients are at risk for VTE as mentioned in several Western and Asian studies.[7],[8],[9],[13],[15],[37] A prospective Asian study (Malaysia) reported the risk of VTE in patients undergoing surgery for femur, hip, and knee replacement without thromboprophylaxis. VTE was diagnosed after a follow-up of clinical signs and venography.[38] The risk factors for hospital-acquired VTE are well characterized and documented.[39] Almost all hospitalized patients have at least one risk factor for VTE, and approximately 40%–50% have the highest (more than three) number of risk factors. Our preeducation control group [29] and postintervention study results were found to have similar proportion of hospitalized patients with highest at-risk VTE.

While our passive intervention of academic detailing was associated with improved VTE prophylaxis rates at our institution, we believe that further improvements are possible. The overall prophylaxis in higher and highest at-risk VTE inpatients was 46.5% compared to 24.7% observed in historical preeducation groups. More than twofold (i.e., 32%–78%) improvement in the implementation of VTE prophylaxis was observed post academic detailing in ICU inpatients. No improvement in the implementation of VTE prophylaxis (7% in pre- and postacademic detailing group) was observed in higher and highest at-risk inpatients admitted in surgical ward. There were no adverse effects observed in patients due to thromboprophylactic measures during the hospital stay.

The overall prophylaxis for VTE significantly improved with an absolute difference of 21% (35%–56%). A meta-analysis on interventions effective at increasing the rates of prophylaxis or appropriate prophylaxis proposed the improvement with a modest absolute difference in the 10%–20% range.[35] This change is attributed to a crucial fact, i.e., improvement in the implementation of VTE prophylaxis in critical care patients admitted in ICU. The absolute difference in the improvement of implementation of VTE prophylaxis in ICU was observed to be 32%. This passive intervention approach showed a significant improvement in the implementation of prophylaxis for VTE in critically ill inpatients compared to other studies reported in a meta-analysis.[39] There is a tremendous scope for improvement in the implementation of prophylaxis for VTE in surgical ward. We hope to achieve it with active intervention strategies. As there was no improvement in the use of prophylaxis for VTE in surgery inpatients post academic detailing, we tried to identify the reasons through a focus group discussion with the surgeons. The reasons were as follows:

  1. Fear of increased bleeding risk in postsurgical inpatients and mobility of inpatients within the first 48 hours
  2. They hardly came across with deep-vein thrombosis symptoms postsurgery in any of their patients during the follow-up months (between 1 and 3 months). They believed that there is a very low incidence of VTE in hospitalized patients in India as compared to the Western countries due to lifestyle differences. Studies proving VTE due to hospitalization through a follow-up color Doppler evidence are negligible. The general and orthopedic surgeons suggested for a study to identify objective evidence of VTE due to hospitalization and surgery through a follow up doppler ultrasonography.


Limitations

The foremost limitation of this study was the absence of a prospective control group. Therefore, we cannot fully attribute the changes in the quantity and quality of VTE prophylaxis solely to the academic detailing intervention. When implementing an institution-wide program, it is difficult to have a coincident control group that is not influenced by the intervention program. Therefore, we used a historical control (preeducation) group to measure the results of the intervention program. The second-most important limitation is that this was a study where we did not collect data on either the incidence of VTE in the patients at our institution or the clinical outcomes for patients who did or did not receive VTE prophylaxis. This study did not focus on care outcomes. Few clinical trials of VTE on surgical patients employed Doppler USG for the identification of VTE. As follow-up color Doppler bears an extra cost burden on patient, it is uncommonly used in clinical practice.


  Conclusions Top


This passive intervention of academic detailing for VTE prophylaxis had a significant impact on the implementation of ACCP guidelines for prophylaxis in critically ill inpatients admitted in ICU compared to surgery inpatients. The overall prophylaxis for at-risk VTE inpatients also improved particularly in higher and highest-risk inpatients, but postsurgery inpatients had a similar lowest usage. Thromboprophylaxis underutilization in surgical ward needs a mixed intervention approach for better results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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