Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients

Abstract

Background: Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis.

Methods and results: We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis. We randomized 2493 patients (82% on Medical Services) from 25 study sites to the intervention group (n=1238), in which the responsible physician was alerted by another hospital staff member, or the control group (n=1255), in which no alert was issued. The primary end point was symptomatic, objectively confirmed VTE within 90 days. Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis as control subjects (46.0% versus 20.6%; P<0.0001). The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25), but the difference did not achieve statistical significance. The rate of major bleeding at 30 days in the alert group was similar to that in the control group (2.1% versus 2.3%; P=0.68).

Conclusions: A strategy of direct notification of the physician by a staff member increases prophylaxis use and leads to a reduction in the rate of symptomatic VTE in hospitalized patients. However, VTE prophylaxis continues to be underused even after physician notification, especially among Medical Service patients.

Trial registration: ClinicalTrials.gov NCT00409136.

Conflict of interest statement

CONFLICT OF INTEREST DISCLOSURES

Gregory Piazza, MD- none

Erin J. Rosenbaum, BA- none

William Pendergast, MD- sanofi-aventis (Research Grant > $10,000, Speaker’s Bureau > $10,000, Consultant/Advisory Board < $10,000); Pfizer (Speaker’s Bureau < $10,000); Novartis (Speaker’s Bureau < $10,000)

Joseph O. Jacobson, MD- none

Robert C. Pendleton, MD- none

Gordon D. McLaren, MD- sanofi-aventis (Research Grant > $10,000); Bristol-Myers Squibb (Research Grant > $10,000)

C. Gregory Elliott, MD- none

Scott M. Stevens, MD- none

William F. Patton, MD- St. Joseph Mercy Health System (Honoraria < $10,000) Ousama Dabbagh, MD- Bristol-Myers Squibb (Research Grant > $10,000); Pfizer (Research Grant > $10,000); Missouri Society of Respiratory Therapists (Honoraria < $10,000)

Marilyn D. Paterno, MBI- none

Elaine Catapane, MEd, MT- none

Zhongzhen Li, MD- none

Samuel Z. Goldhaber, MD- sanofi-aventis (Research Grant > $10,000, Consultant/Advisory Board < $10,000); Eisai (Research Grant > $10,000, Consultant/Advisory Board < $10,000); Boehringer Ingelheim (Research Grant > $10,000, Consultant Advisory Board < $10,000); Bristol-Myers Squibb (Consultant Advisory Board < $10,000)

Figures

Figure 1

Flow of patients through each stage of the trial.

Figure 2

Kaplan-Meier estimates of the absence of symptomatic deep vein thrombosis or pulmonary embolism in the intervention group and the control group (p = 0.31 by the log-rank test for comparison of the outcome between groups at 90 days).