Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial

Alex C Spyropoulos; Mark Goldin; Ioannis Koulas; Jeffrey Solomon; Michael Qiu; Sam Ngu; Kolton Smith; Tungming Leung; Kanta Ochani; Fatima Malik; Stuart L Cohen; Dimitrios Giannis; Sundas Khan; Thomas McGinn

doi:10.1016/j.jacadv.2023.100597

Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial

JACC Adv. 2023 Sep 13;2(8):100597. doi: 10.1016/j.jacadv.2023.100597. eCollection 2023 Oct.

Authors

Alex C Spyropoulos^{1

2}, Mark Goldin^{1

2}, Ioannis Koulas¹, Jeffrey Solomon¹, Michael Qiu¹, Sam Ngu³, Kolton Smith⁴, Tungming Leung⁵, Kanta Ochani¹, Fatima Malik¹, Stuart L Cohen^{1

6}, Dimitrios Giannis¹, Sundas Khan^{7

8}, Thomas McGinn^{7

9}

Affiliations

¹ Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA.
² Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
³ Department of Hematology/Oncology, Lenox Hill Hospital at Northwell Health, New York, New York, USA.
⁴ Department of Internal Medicine, Lenox Hill Hospital at Northwell Health, New York, New York, USA.
⁵ Biostatistics Unit, Office of Academic Affairs, Northwell Health, Hempstead, New York, USA.
⁶ Department of Radiology, North Shore University Hospital at Northwell Health, Manhasset, New York, USA.
⁷ Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
⁸ Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas, USA.
⁹ CommonSpirit Health, Chicago, Illinois, USA.

Abstract

Background: Thromboprophylaxis for medically ill patients during hospitalization and postdischarge remains underutilized. Clinical decision support (CDS) may address this need if embedded within workflow, interchangeable among electronic health records (EHRs), and anchored on a validated model.

Objectives: The purpose of this study was to assess the clinical impact of a universal EHR-integrated CDS tool based on the International Medical Prevention Registry on Venous Thromboembolism plus D-Dimer venous thromboembolism model.

Methods: This was a cluster randomized trial of 4 tertiary academic hospitals from December 21, 2020 to January 21, 2022. Inpatients over age 60 with key medical illnesses were eligible. We embedded CDS at admission and discharge. Hospitals were randomized to intervention (CDS; n = 2) vs usual care (n = 2) groups. The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included venous, arterial, and total thromboembolism, major bleeding, and all-cause mortality through 30 days postdischarge.

Results: After exclusions, 10,699 of 19,823 patients were analyzed. Intervention group tool adoption was 77.8%. Appropriate thromboprophylaxis was increased at intervention hospitals, both inpatient (80.1% vs 72.5%, OR: 1.52, 95% CI: 1.39-1.67) and at discharge (13.6% vs 7.5%, OR: 1.93, 95% CI: 1.60-2.33). There were fewer venous (2.7% vs 3.3%, OR: 0.80, 95% CI: 0.64-1.00), arterial (0.25% vs 0.70%, OR: 0.35, 95% CI: 0.19-0.67), and total thromboembolisms (2.9% vs 4.0%, OR: 0.71, 95% CI: 0.58-0.88) at intervention hospitals. Major bleeding was rare and did not differ between groups. Mortality was higher at intervention hospitals (9.1% vs 7.0%, OR: 1.32, 95% CI: 1.15-1.53).

Conclusions: EHR-embedded CDS increased appropriate thromboprophylaxis and reduced thromboembolism without increasing major bleeding in medically ill inpatients. Mortality was higher at intervention hospitals.

Keywords: IMPROVE-DD VTE score; arterial thromboembolism; clinical decision support; clinical prediction rule; medical inpatient; thromboprophylaxis; venous thromboembolism.