Science of health care delivery

Venous thromboembolism (VTE) is a common and potentially preventable cause of morbidity and mortality for the hospitalized patient. Hospitalization increases the incidence of VTE more than 100-fold compared with community residents. ¹ For hospitalized patients, thrombotic events are nearly twice as likely to be pulmonary emboli compared to deep vein thrombosis of the leg. ¹ Pulmonary embolism (PE) accounts for nearly 10% of all hospital deaths and is one of the most common preventable causes of in-hospital mortality. Often, these pulmonary emboli occur without prior warning and sudden death may be the initial symptom of disease. The risk of VTE continues beyond the hospital stay, with nearly half of all thrombotic events occurring up to 90 days post dismissal.^2,3 Underscoring the magnitude of this problem is the fact that there are more than 23 million non-surgical hospital admissions and 50 million inpatient procedures performed each year in the United States.^4,5 Although surgery is a well-established risk factor for VTE, the majority of VTE events occur in non-surgical patients. ⁶ With a growing trend toward expanded outpatient delivery of medical and surgical health care, only the very sickest patients are currently hospitalized. VTE prophylaxis is cost effective, safe, affordable and reduces VTE rates by 50–70%, with an acceptably low risk of major bleeding. Without prophylaxis, VTE rates are high for both surgical and non-surgical hospitalized patients. Despite these facts, the utilization rates of guideline-endorsed VTE prophylaxis remain imperfect. ⁷

The science of health care delivery aims to identify and advance variables central to the successful implementation and conveyance of strategies for improving the quality, outcomes and cost of individual and societal health care. Scientific inquiry in this new and growing field combines data analysis, health care delivery research and engineering principles to accomplish these goals. Health care systems research focuses on the design and refinement of care delivery systems and processes to improve efficiencies, diminish errors, and improve the access, quality, and safety of medical care delivery. By incorporating practice stakeholders, scientific information, systems engineering and knowledge dissemination, this new field of medical science strives to transform health care delivery. In the current issue of Vascular Medicine, Ma and colleagues address the science of health care delivery of appropriate VTE prophylaxis in patients hospitalized at a university-affiliated Montreal hospital. ⁸ After documenting a high rate of preventable venous thrombotic events at their institution, this group implemented an institution-wide policy to improve thromboprophylaxis implementation. ⁹ This policy included education, pocket card distribution to members of the health care team, and preprinted admission order sets for surgical patients to encourage proper VTE prophylaxis use. Compared to the pre-implementation period, ⁹ this group was able to demonstrate a 42% reduction in the potentially preventable VTE rate (39.3% from 67.7%) with their institution-wide VTE prevention effort. Omission of VTE prophylaxis, however, remained the primary reason for inadequacy of VTE prevention in this study.

There are a number of reasons for inadequacy of VTE prophylaxis delivery. These include concerns regarding the risk of bleeding, economic burden, and unfamiliarity, or non-endorsement of published guidelines. ¹⁰ As found by Ma and colleagues, ⁸ one of the primary reasons for low compliance with VTE prophylaxis appears to be omission. With the pressures of a busy practice and the growing trend of hospitalization of only the most complicated and sickest patients, it is easy to understand overlooking VTE prophylaxis. A number of strategies have been developed for improving guideline adherence and adoption of best practices. These include information dissemination through continuing education, real-time systems of audit and feedback, computerized ordering algorithms and reminders, and quality improvement projects with designated implementation and surveillance personnel. ¹⁰ Passive information dissemination strategies appear to be inferior to active strategies. Computer-based systems with electronic reminders likely improve success rates. Multiple active strategies improve outcomes compared to single interventions. Continued refinement of the intervention through serial audits is ideal.

An electronic order set employing an ‘opt-out’ strategy with a required explanation for omission has dramatically improved VTE prophylaxis delivery rates at our institution (unpublished data). Another group found that a system employing standardized electronic orders, VTE risk stratification systems such as the Caprini scoring system, electronic reminders, and practice audits reduced VTE rates by an impressive 84%.^11,12 In the end, the new science of health care delivery should be called upon to develop tools and systems to assist providers in the implementation of health care known to improve patient outcomes. Executing the delivery of appropriate VTE prophylaxis would seem to be an excellent place to start. Electronic strategies to ‘omit the omissions’ of VTE prophylaxis would be a welcome tool to any medical toolbox.