Timing of Post-discharge Venous Thromboembolic Events and Effect of Pharmacologic Prophylaxis in Hospitalized Patients Paul J. Grant MD, Todd Greene PhD, Steven J. Bernstein MD, Julie Wietzke, Kristen Cowan, Elizabeth McLaughlin, Scott Kaatz DO, David Paje MD, Bobby Lee MD, Scott A. Flanders MD Patient Sample VTE Events in 90-day Post-discharge Period Methods fd Background Conclusions Michigan Hospital Medicine Safety Consortium Hospitalized patients are known to be at increased risk for venous thromboembolism (VTE) VTE prophylaxis measures are universally recommended by national guidelines and endorsed by regulatory bodies including The Joint Commission With shorter lengths of hospital stay, more VTE events occur after discharge However, the timing of post-discharge VTE events and the effect of pharmacologic prophylaxis exposure during hospitalization are not well understood Post-discharge VTE in medical patients is uncommon Almost ½ of patients had a subsequent inpatient stay prior to the post-discharge VTE event The trajectories of time to VTE events do not appear to be associated with receipt of pharmacologic prophylaxis on hospital admission Most VTE events in patients without a subsequent inpatient stay occurred within 35 days post-discharge A state-wide collaborative designed to prevent adverse events in hospitalized medical patients Blue Cross Blue Shield of Michigan and Blue Care Network quality initiative using a voluntary pay-for- performance model Web-based data registry was used for data collection Quarterly meetings are held where consortium data and best practices are shared Population: Medical patients hospitalized at 35 hospitals in Michigan between January 2011 and December 2012 Data collection: Complete medical record review and 90-day phone follow-up by a full-time medical record abstractor at each hospital. Standard clinical data including all VTE risk factors were collected Inclusion criteria: patients who had not had a VTE during their initial hospitalization and were discharged to home or an assisted-living facility and were not re- hospitalized prior to developing a post-discharge VTE The following patients were excluded: - age < 18 years - pharmacologic prophylaxis contraindicated - admissions for VTE, surgery, or comfort care - elevated INR or on systemic anticoagulation on admit - patients transferred to the ICU VTE prophylaxis on admission was defined as receiving appropriate pharmacologic therapy on day 1 or day 2 of hospitalization. Acceptable therapies included unfractionated heparin, LMWH, and fondaparinux Outcomes: VTE events in the 90-day follow-up period Analysis Patient Characteristics by Prophylaxis Status Cumulative Proportion of VTE Events Using multivariable logistic regression, VTE outcomes were adjusted for receipt of pharmacologic prophylaxis on admission, patient age, length of stay, and Caprini score (a risk score for probability of developing a VTE) CharacteristicTotalProphylaxis on admission No prophylaxis on admission p - value VTE during follow-up6241 (66%)21 (34%)- Age (years) Length of stay (days) Caprini score ,260 eligible patients 25,423 patients 247 (0.97%) with VTE during 90-day follow-up 132 discharged home or to assisted-living 62 with no subsequent hospitalization Excluded: Systemic anticoagulation INR ≥2 Prophylaxis contraindicated Excluded: Systemic anticoagulation INR ≥2 Prophylaxis contraindicated Excluded: 58 re-hospitalized prior to VTE event 12 unknown readmission status Excluded: 58 re-hospitalized prior to VTE event 12 unknown readmission status Limitations Analysis limited to prophylaxis on admission Use of mechanical prophylaxis was not considered Phone follow-up rates averaged only 60% Author Institutions University of Michigan Health System, VA Ann Arbor Healthcare System, Henry Ford Health System, Hurley Medical Center, Oakwood Health System