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Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE

A Prospective Cohort Study

Lau, Brandyn D. MPH, CPH; Arnaoutakis, George J. MD; Streiff, Michael B. MD, FACP; Howley, Isaac W. MD, MPH; Poruk, Katherine E. MD; Beaulieu, Robert MD; Ellison, Trevor A. MD; Van Arendonk, Kyle J. MD, PhD; Kraus, Peggy S. Pharm D, CACP; Hobson, Deborah B. BSN; Holzmueller, Christine G. BLA; Black, James H. III MD, FACS; Pronovost, Peter J. MD, PhD, FCCM; Haut, Elliott R. MD, PhD, FACS

doi: 10.1097/SLA.0000000000001512
ORIGINAL ARTICLES
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Objective: To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis.

Background: Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits.

Methods: This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013–2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey.

Results: At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001).

Conclusions: Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.

*Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

§Armstrong Institute for Patient Safety and Quality

Department of Surgery, University of Pennsylvania, Philadelphia, PA

||The Armstrong Institute for Patient Safety, Johns Hopkins University School of Medicine, Baltimore, MD

**Department of Medicine at the Johns Hopkins University School of Medicine

††Department of Pharmacy at the Johns Hopkins Hospital

‡‡Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

§§Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Reprints: Brandyn D. Lau, MPH, CPH, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Osler 714A, Baltimore, MD 21287. E-mail: blau2@jhmi.edu.

1 #Authors contributed equally to this manuscript and are co-first authors.

Disclosure: B.D.L., E.R.H., M.B.S., and P.J.P. are supported by a contract (CE-12-11-4489) from the Patient-Centered Outcomes Research Institute (PCORI) entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” B.D.L. is supported by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant and a contract (AD-1306-03980) from the Patient-Centered Outcomes Research Institute (PCORI) entitled “Patient Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department.” M.B.S. has received research funding from Bristol Myers Squibb, honoraria for CME lectures from Sanofi-Aventis and consulted for Sanofi-Aventis, Eisai, Daiichi-Sankyo, Boehringer-Ingelheimand Janssen HealthCare and has given expert witness testimony in various medical malpractice cases.

E.R.H. was the Primary Investigator of a Mentored Clinician Scientist Development Award K08 1K08HS017952-01 from the AHRQ entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” E.R.H. receives royalties from Lippincott, Williams, & Wilkins for a book, “Avoiding Common ICU Errors” and consulting fees from VHA. P.J.P. reports consultancy fees from the Association for Professionals in Infection Control and Epidemiology, Inc., grant or contract support from the Agency for Healthcare Research & Quality, National Institutes of Health, Robert Wood Johnson Foundation, and The Commonwealth Fund, honoraria from various hospitals and the Leigh Bureau (Somerville, NJ), and royalties from his book, “Safe Patients Smart Hospitals.” The authors declare no conflicts of interest.

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