Introduction: Patients that are admitted to the inpatient subspecialty GI service who are eligible for venous thromboembolism (VTE) prophylaxis are routinely being managed with unfractionated heparin (UFH) instead of low-molecular weight heparin (LMWH), resulting in more costly care. LMWH has a lower tendency towards bleeding, is cheaper (per hospital day) and is dosed on a less frequent basis when compared to UFH.
Methods: As part of continuous quality improvement (QI), we sought to increase the use of LMWH for VTE prophylaxis in this unique patient population to reduce the patient cost and increase the value of care. The Plan-Do-Study-Act (PDSA) model was used to allow for rapid idea development, intervention implementation, outcome measurement and turnaround if another intervention was to be tried. To measure the magnitude of the problem, admission data was reviewed for the length of one resident rotation cycle (5 weeks). Intervention(s) were devised after interviewing the residents at the end of their service period. Two interventions were devised: 1) Placing a reminder placard on the computer monitor bezel and 2) incorporate VTE prophylaxis education during the rotation orientation session. Data was again collected after the interventions over another 5 week resident cycle.
Results: Before the intervention implementation, 97 patients were admitted to the resident service over a 5 week rotation period. Of these, 39 (40%) were eligible for VTE prophylaxis and 33 (85%) were managed with UFH compared to just 5 (13%) managed with LMWH. One patient refused VTE prophylaxis. After the combined intervention, 110 patients were admitted over the 5 week rotation period. Of these, 56 (51%) were eligible for VTE prophylaxis and 53 (95%) of them were managed with LMWH. This represented an increase of LMWH use by 7 times and reduced patient cost of VTE prophylaxis by 57% (2015 dollars) when compared to the previous rotation cycle. Reasons for prophylaxis ineligibility included active GI hemorrhage, already being on therapeutic anticoagulation, hospitalization of of < 24 hours and planned procedure within 24 hours.
Conclusion: A simple, cost-effective, durable and brief intervention (using two QI strategies) can lead to a decrease in VTE prophylaxis cost and thus improvement in value.