Effect of Real-time Patient-Centered Education Bundle on Administration of Venous Thromboembolism Prevention in Hospitalized Patients

Abstract

Importance: Numerous interventions have improved prescription of venous thromboembolism (VTE) prophylaxis; however, many prescribed doses are not administered to hospitalized patients, primarily owing to patient refusal.

Objective: To evaluate a real-time, targeted, patient-centered education bundle intervention to reduce nonadministration of VTE prophylaxis.

Design, setting, and participants: This nonrandomized controlled, preintervention-postintervention comparison trial included 19 652 patient visits on 16 units at The Johns Hopkins Hospital, Baltimore, Maryland, from April 1 through December 31, 2015. Data analysis was performed from June 1, 2016, through November 30, 2017, on an intention-to-treat basis.

Interventions: Patients on 4 intervention units received a patient-centered education bundle if a dose of VTE prophylaxis medication was not administered. Patients on 12 control units received no intervention.

Main outcomes and measures: Conditional odds of nonadministration of doses of VTE prophylaxis (primary outcome) before and after the intervention on control vs intervention units. Reasons for nonadministration (ie, patient refusal and other) and VTE event rates (secondary outcomes) were compared.

Results: A total of 19 652 patient visits where at least 1 dose of VTE prophylaxis was prescribed were included (51.7% men; mean [SD] age, 55.6 [17.1] years). Preintervention and postintervention groups were relatively similar in age, sex, race, and medical or surgery unit. From the preintervention period to the postintervention period, on intervention units, the conditional odds of VTE prophylaxis nonadministration declined significantly (9.1% [95% CI, 5.2%-16.2%] vs 5.6% [95% CI, 3.1%-9.9%]; odds ratio [OR], 0.57; 95% CI, 0.48-0.67) compared with no change on control units (13.6% [95% CI, 9.8%-18.7%] vs 13.3% [95% CI, 9.6%-18.5%]; OR, 0.98; 95% CI, 0.91-1.07; P < .001 for interaction). The conditional odds of nonadministration owing to patient refusal decreased significantly on intervention units (5.9% [95% CI, 2.6%-13.6%] vs 3.4% [95% CI, 1.5%-7.8%]; OR, 0.53; 95% CI ,0.43-0.65) compared with no change on control units (8.7% [95% CI, 5.4%-14.0%] vs 8.5% [95% CI, 5.3%-13.8%]; OR, 0.98; 95% CI, 0.89-1.08; P < .001 for interaction). On intervention units, the conditional odds of nonadministration owing to reasons other than patient refusal decreased (2.3% [95% CI, 1.5%-3.4%] vs 1.7% [95% CI, 1.1%-2.6%]; OR, 0.74; 95% CI, 0.58-0.94), with no change on control units (3.4% [95% CI, 2.7%-4.4%] vs 3.3% [95% CI, 2.6%-4.2%]; OR, 0.98; 95% CI, 0.87-1.10; P = .04 for interaction). No differential effect occurred on medical vs surgical units (OR, 0.86; 95% CI, 0.60-1.23; P = .41 for interaction). There was no statistical difference in the proportion of VTE events among patients on intervention vs control units (0.30% vs 0.18%; OR, 0.60; 95% CI, 0.16-2.23).

Conclusions and relevance: In this study, a targeted patient-centered education bundle significantly reduced nonadministration of pharmacologic VTE prophylaxis in hospitalized patients. This novel strategy improves health care quality by leveraging electronic data to target interventions in real time for at-risk patients.

Trial registration: ClinicalTrials.gov Identifier: NCT02402881.

Conflict of interest statement

Conflict of Interest Disclosures: Drs Haut, Aboagye, Farrow, Owodunni, Webster, Pronovost, and Streiff, Ms Shaffer, and Mr Lau reported support by contract CE-12-11-4489 and/or contract DI-1603-34596 from the Patient-Centered Outcomes Research Institute (PCORI). Drs Haut and Streiff and Mr Lau reported support by grant 1R01HS024547 from the Agency for Healthcare Research and Quality (AHRQ) and grant R21HL129028 from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH). Dr Haut and Mr Lau reported receiving support by contract W81XWH-16-R-BAA1 from the Department of Defense. Dr Haut reported support by contract PCS-1511-32745 from PCORI; serving as a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism—Every Patient, Every Time” VHA/Vizient IMPERATIV Advantage Performance Improvement Collaborative; receiving royalties from Lippincott, Williams & Wilkins for Avoiding Common ICU Errors; and receiving compensation for authoring a paper commissioned by the National Academies of Medicine. Ms Hobson reported giving expert witness testimony in various medical malpractice cases. Dr Pronovost reported consultancy fees from the Association for Professionals in Infection Control and Epidemiology, Inc, grant or contract support from the AHRQ, NIH, Robert Wood Johnson Foundation, PCORI, and The Commonwealth Fund; honoraria from various hospitals and the Leigh Bureau; and royalties from his book, Safe Patients Smart Hospitals. Dr Streiff reported receiving research funding from Boehringer Ingelheim, Janssen Pharmaceutica, Portola Pharmaceuticals, and Hoffman–La Roche; consulting for Janssen Pharmaceutica and Portola Pharmaceuticals; and giving expert witness testimony in various medical malpractice cases. Mr Lau reported support by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant and contract AD-1306-03980 from PCORI and support by grant R13HS026350 from the AHRQ. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram of Patients Receiving the Education Bundle Intervention

Patient visits reflect prescribed pharmacologic venous thromboembolism (VTE) prophylaxis doses. A missed prophylaxis dose triggers an intervention; the bedside nurse and patients who refused at least 1 dose are delivered the patient education bundle. The bundle is only delivered once to participants.

Figure 2.. Conditional Proportion of Missed Doses of Venous Thromboembolism (VTE) Prophylaxis for Intervention and Control Arms on Medical and Surgical Units

Data are stratified by month.