A Amin

AB Haynes

AN Amin

AT Cohen

AX Garg

Diane Sliwka

E. O’Malley

F Dentali

FA Anderson Jr

FA Michota

G Maynard

GM Peterson

J Lomas

JL Schnipper

Margaret C. Fang

MD Cabana

N Kucher

P Durieux

P Pronovost

PR Dexter

SL Cohn

SZ Goldhaber

V Erasmus

VF Tapson

WH Geerts

Y Reisman

English

PubMed

Crossref

EDITORIAL
Venous Thromboembolism Prophylaxis in the United States: Still
Room for Improvement
Diane Sliwka, MD and Margaret C. Fang, MD, MPH
Division of Hospital Medicine, The University of California San Francisco, San Francisco, CA, USA.
J Gen Intern Med 25(6):484–6
DOI: 10.1007/s11606-010-1350-9
© The Author(s) 2010. This article is published with open access at
Springerlink.com
V enous thromboembolism (VTE) is one of the most com-mon, life-threatening cardiovascular conditions in the
United States, causing approximately 200,000 deaths each
year.1,2 Hospitalized patients are particularly vulnerable to
VTE, with approximately 42.5% of all hospitalized medical
patients considered to be at increased VTE risk.3 As a result,
multiple guidelines, including the prominent American College
of Chest Physicians Guidelines on Antithrombotic and Throm-
bolytic Therapy, support the administration of measures to
prevent VTE in appropriate patients.4 Although pharmacologic
and, to a lesser degree, mechanical forms of prophylaxis, have
been shown to significantly reduce the risk of VTE5, several
studies have shown that many hospitalized patients do not
receive VTE prophylaxis.6–8 In this issue of the Journal of
General Internal Medicine, Rothberg et al. present a large
analysis of VTE prophylaxis rates among medical patients
admitted to 376 acute-care facilities in the United States,
finding that a striking 64% of patients with at least a moderate
risk of VTE failed to receive VTE prophylaxis by the second day
of their hospitalization.9
Using an administrative database of greater than 350,000
medical inpatients with primary diagnoses indicating a mod-
erate to high-risk of VTE, this study revealed not only overall
low rates of VTE prophylaxis, but also considerable variability
in utilization rates across hospitals and providers. Despite
some differences in patient selection and definition of VTE
prophylaxis, the low administration rates are consistent with
other similar multi-institutional studies.6,10,11 A unique find-
ing of the study was that, although prophylaxis rates varied
among individual physicians, physician practice seemed to
cluster around institutional means. Patients with similar VTE
risk profiles had widely divergent likelihoods of receiving VTE
prophylaxis depending on the admitting hospital, with vari-
ability observed by hospital size, type, and region. This
variation in clinical practice among hospitals suggests that
strategies aimed at improving prophylaxis rates should be
directed at the institutional level.
There are several limitations to this observational study
using administrative data. One is the lack of information on
clinical decision-making with regard to VTE prophylaxis, such
as contraindications to pharmacologic VTE prophylaxis or
patient preference. For example, a prior study found that
contraindications excluded 10% of medical patients from
receiving pharmacologic VTE prophylaxis.6 It was possible that
some services may not have been consistently or uniformly
captured, as they were dependent on accurate billing and
utilization codes. Finally, using ICD-9 coded clinical diagnoses
to classify patients into varying levels of VTE risk may be
subject to misclassification and cannot completely capture the
unique circumstances of individual patients, such as comfort
care or highly ambulatory individuals who were thought to be
at low VTE risk.
Nevertheless, even allowing that some patients in this
analysis may not have required or desired VTE prophylaxis,
the low administration rates in the study still suggest that
significant numbers of patients fail to receive appropriate VTE
prophylaxis. That variation in prophylaxis administration
seemed to be more dependent on region and hospital practice
as opposed to individual patient factors highlights the need for
continued study in system-wide and institutionally-directed
interventions. The direction of further research should now
focus less on describing the scope of the problem and more on
how to best address barriers to quality improvement and most
effectively implement solutions.
STRATEGIES TO IMPROVE VTE PROPHYLAXIS
Expert panels, national quality organizations, and regulatory
bodies have aligned to address VTE prevention. The Joint
Commission, the National Quality Forum, the Centers for
Medicare & Medicaid Services, and the Agency for Healthcare
Research and Quality (AHRQ) have developed measure-based
initiatives such as quality indicators, public reporting, and
incentive and disincentive programs targeting VTE prophylaxis
rates. These have provided the impetus for national collabora-
tives such as the Society of Hospital Medicine (SHM) VTE
Prevention Collaborative12 and the incorporation of VTE
prophylaxis in the Surgical Care Improvement Project (SCIP).
The Surgeon General issued a “Call to Action to Prevent Deep
Venous Thrombosis and Pulmonary Embolism” in 2008,
further emphasizing VTE prevention as a major public health
concern.13 Despite efforts from leading regulatory and quality
improvement agencies to promote awareness and motivation
for VTE prophylaxis, as well as clear evidence that the impact
of VTE prevention efforts can be large, what seem to be
straightforward interventions are frequently challenging to
implement in actual practice.14
The simplest but probably least effective strategy is attempt-
ing to change practice through passive methods such as thePublished online February 14, 2010
JGIM
484
development and publication of guidelines. Although guide-
lines are vital in summarizing best practice recommendations
and expert opinion, even well-known guidelines, such as those
recommending VTE prophylaxis, face multiple barriers in
terms of assimilation into clinical practice.9,15–17 The dissem-
ination of locally specific recommendations can be more
effective, particularly as part of a multipronged strategy.18
More active strategies, such as targeted education about
VTE prophylaxis,19 have shown effectiveness in improving VTE
prophylaxis but are limited in reach and retention over time.
Relying on individual clinicians to remember and apply
information correctly at each clinical encounter is inefficient
and frequently ineffective. An important area for further
research should be directed in how to best implement ‘micro’
level (i.e., at the point of care) interventions to assist providers
at the time of the clinical encounter so as to encourage specific
behaviors. Examples of micro-level interventions that have
been shown to improve VTE prophylaxis rates include auto-
mated reminder systems such as computer alerts20 and
protocols embedded in admission and transfer order sets.20
Computer alerts have been shown to improve VTE prophylaxis
ordering rates23,24 and were associated with a 41% reduction
in the 90-day incidence of VTE in one study.20 Successful
strategies acknowledge that clinical care is complex and fast-
paced, and attempt to integrate interventions into usual
clinical workflow. Interventions that embed VTE prophylaxis
into standardized, pre-existing order sets are more effective
than asking physicians to complete separate, free-standing
VTE-specific order sets.12 Simple interventions such as check-
lists may also be effective, having been shown to dramatically
improve clinical outcomes in other settings such as reducing
catheter-related blood stream infections21, postoperative com-
plications, and surgery-related deaths.22
Enhancing clinical decision-support through building in
reminder-systems and evidence-based recommendations into
computerized order sets and electronic medical records, has
great potential.25 A 2005 meta-analysis of such systems found
improvements in specific processes of care 62% of the time,
though only 13% showed improved patient outcomes. Barriers
to effective use included poor workflow integration, misaligned
relevance to patients at the point of care, and provider
disagreement with recommendations.25–27 Importantly, the
variability in uptake of computerized medical record systems
as well as the heterogeneity in decision-support capability
across specific institutions are barriers to widespread adoption
of this strategy at present.
Measurement, through real time audit and feedback, is an
essential component of any improvement strategy. Combining
audit and feedback with other effective strategies such as
reminder systems and decision support at the point of care, have
been shown to improve VTE prophylaxis to near 100%.12
However, there are numerous challenges in being able to collect
data in real time such that individual providers can respond to
audit and feedback. One such intervention, the use of a ‘quality
dashboard’ to provide summary reports of predetermined clinical
measures, is an example of a specific tool that can contribute to
the success of high performing institutions.28 Quality dash-
boards can help hospital leadership guide the quality agenda,
create accountability for high-priority measures29 and provide
actionable information to effect change at the point-of-care.30
Finally, catalyzing real improvement across institutions
would benefit from the adoption of general frameworks of
effective quality improvement strategies. One example is the
VTE Prevention Collaborative supported by the Society of
Hospital Medicine, the Institute for Healthcare Improvement,
and AHRQ.12 This collaborative seeks to disseminate effective
strategies shown to improve VTE care as well as provide
guidance and mentorship to individual hospitals at the local
level to help address barriers to implementation12. By pooling
knowledge and best practices, providing specific toolkits for
quality improvement, and tailoring solutions to local insti-
tutional culture, such initiatives help disseminate effective
solutions and reduce duplication of efforts. Identifying
characteristics of high-performing institutions can provide
templates for other hospitals to model their efforts. Features
of high-performing institutions include a culture that welcomes
quality improvement and change, supports and retains individ-
ual quality improvement “champions”, and institutional trans-
parency and accountability.28
CONCLUSION
Significant numbers of hospitalized patients in the United
States fail to receive appropriate VTE prophylaxis despite clear
guidelines and widespread efforts to raise VTE awareness. The
study by Rothberg et al. highlights the magnitude and
widespread nature of the problem, as well as the wide
variability in practice across different institutions9. Efforts
should now focus on disseminating effective strategies to
change clinical practice, both at the point of care and
institutional level, and seek out high-performing institutions
as models of effective practice change.
Open Access: This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
Corresponding Author: Diane Sliwka, MD; Division of Hospital
Medicine, The University of California San Francisco, 533
Parnassus Ave., Box 0131, San Francisco, CA 94143, USA
(e-mail: dsliwka@medicine.ucsf.edu).
REFERENCES
1. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thrombo-
embolism: The seventh ACCP conference on antithrombotic and throm-
bolytic therapy. Chest. 2004;126(3 Suppl):338S–400S.
2. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based
perspective of the hospital incidence and case-fatality rates of deep vein
thrombosis and pulmonary embolism. the worcester DVT study. Arch
Intern Med. 1991;151(5):933–8.
3. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism
risk and prophylaxis in the acute hospital care setting (ENDORSE
study): A multinational cross-sectional study. Lancet. 2008;371
(9610):387–94.
4. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous
thromboembolism: American college of chest physicians evidence-based
clinical practice guidelines (8th edition). Chest. 2008;133(6
Suppl):381S–453S.
5. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-
analysis: Anticoagulant prophylaxis to prevent symptomatic venous
thromboembolism in hospitalized medical patients. Ann Intern Med.
2007;146(4):278–88.
485Sliwka and Fang: Venous Thromboembolism Prophylaxis in the United StatesJGIM
6. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism
risk and prophylaxis in the acute hospital care setting (ENDORSE
study): A multinational cross-sectional study. Lancet. 2008;371
(9610):387–94.
7. Tapson VF, Decousus H, Pini M, et al. Venous thromboembolism
prophylaxis in acutely ill hospitalized medical patients: Findings from
the international medical prevention registry on venous thromboembo-
lism. Chest. 2007;132(3):936–45.
8. Goldhaber SZ, Tapson VF, Steering Committee. A prospective registry
of 5, 451 patients with ultrasound-confirmed deep vein thrombosis. Am
J Cardiol. 2004;93(2):259–62.
9. Rothberg MB, Lahti M, Pekow PS, Lindenauer PK. Venous thrombo-
embolism prophylaxis among medical patients at US hospitals. J Gen
Intern Med. 2010.
10. Amin A, Stemkowski S, Lin J, Yang G. Thromboprophylaxis rates in US
medical centers: Success or failure? J Thromb Haemost. 2007;5
(8):1610–6.
11. Amin AN, Stemkowski S, Lin J, Yang G. Inpatient thromboprophylaxis
use in U.S. hospitals: Adherence to the seventh american college of chest
physician’s recommendations for at-risk medical and surgical patients. J
Hosp Med. 2009;4(8):E15–21.
12. Maynard G, Stein J. Designing and implementing effective venous
thromboembolism prevention protocols: Lessons from collaborative
efforts. J Thromb Thrombolysis. 2010;29(2):159–66.
13. Galson SK. The surgeon general’s call for action to prevent deep venous
thrombosis and pulmonary embolism. 2008;2010(2 24 2010).
14. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on
compliance with hand hygiene guidelines in hospital care. Infect Control
Hosp Epidemiol. 2010;31(3):283–94.
15. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow
clinical practice guidelines? A framework for improvement. JAMA.
1999;282(15):1458–65.
16. Cohn SL. Prophylaxis of venous thromboembolism in the US: Improving
hospital performance. J Thromb Haemost. 2009;7(9):1437–45.
17. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah
WJ.Dopractice guidelines guide practice? the effect of a consensus statement
on the practice of physicians. N Engl J Med. 1989;321(19):1306–11.
18. Peterson GM, Drake CI, Jupe DM, Vial JH, Wilkinson S. Educational
campaign to improve the prevention of postoperative venous thrombo-
embolism. J Clin Pharm Ther. 1999;24(4):279–87.
19. Michota FA. Bridging the gap between evidence and practice in venous
thromboembolism prophylaxis: The quality improvement process. J Gen
Intern Med. 2007;22(12):1762–70.
20. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous
thromboembolism among hospitalized patients. N Engl J Med. 2005;352
(10):969–77.
21. Pronovost P, Needham D, Berenholtz S, et al. An intervention to
decrease catheter-related bloodstream infections in the ICU. N Engl J
Med. 2006;355(26):2725–32.
22. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to
reduce morbidity and mortality in a global population. N Engl J Med.
2009;360(5):491–9.
23. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald
CJ. A computerized reminder system to increase the use of preventive care
for hospitalized patients. N Engl J Med. 2001;345(13):965–70.
24. Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E. A clinical
decision support system for prevention of venous thromboembolism:
Effect on physician behavior. JAMA. 2000;283(21):2816–21.
25. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized
clinical decision support systems on practitioner performance and
patient outcomes: A systematic review. JAMA. 2005;293(10):1223–38.
26. Reisman Y. Computer-based clinical decision aids. A review of methods
and assessment of systems. Med Inform (Lond). 1996;21(3):179–97.
27. Schnipper JL, Linder JA, PalchukMB, et al. “Smart forms” in an electronic
medical record: Documentation-based clinical decision support to improve
disease management. J AmMed Inform Assoc. 2008;15(4):513–23.
28. Meyer APD, Silow-Carroll SMBAMSW, Kutyla TMLA, Stepnick LS,
Ribowski LS. Hospital quality: Ingredients for success overview and
lessons learned. The Commonwealth Fund. 2004 July.
29. Kroch EP, Vaughn TP, Koepke MJ, MHA, et al. Hospital boards and
quality dashboards. Journal of Patient Safety. 2006;2(1):10-19.
30. Stein J, Chernetsky Tejedor S, Shabbir H, O’Malley E. Situational
awareness improves prevalence of VTE prophylaxis on multiple nursing
units. Journal of Hospital Medicine. 2008(3(S1):41).
486 Sliwka and Fang: Venous Thromboembolism Prophylaxis in the United States JGIM


Venous Thromboembolism Prophylaxis in the United States: Still Room for Improvement

Sliwka, Diane

Fang, Margaret C.

eScholarship - University of California

eScholarshipTitleVenous Thromboembolism Prophylaxis in the United States: Still Room for ImprovementPermalinkhttps://escholarship.org/uc/item/6gr7q0thJournalJournal of General Internal Medicine, 25(6)ISSN1525-1497AuthorsSliwka, DianeFang, Margaret C.Publication Date2010-06-01DOI10.1007/s11606-010-1350-9 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaEDITORIALVenous Thromboembolism Prophylaxis in the United States: StillRoom for ImprovementDiane Sliwka, MD and Margaret C. Fang, MD, MPHDivision of Hospital Medicine, The University of California San Francisco, San Francisco, CA, USA.J Gen Intern Med 25(6):484–6DOI: 10.1007/s11606-010-1350-9© The Author(s) 2010. This article is published with open access atSpringerlink.comV enous thromboembolism (VTE) is one of the most com-mon, life-threatening cardiovascular conditions in theUnited States, causing approximately 200,000 deaths eachyear.1,2 Hospitalized patients are particularly vulnerable toVTE, with approximately 42.5% of all hospitalized medicalpatients considered to be at increased VTE risk.3 As a result,multiple guidelines, including the prominent American Collegeof Chest Physicians Guidelines on Antithrombotic and Throm-bolytic Therapy, support the administration of measures toprevent VTE in appropriate patients.4 Although pharmacologicand, to a lesser degree, mechanical forms of prophylaxis, havebeen shown to significantly reduce the risk of VTE5, severalstudies have shown that many hospitalized patients do notreceive VTE prophylaxis.6–8 In this issue of the Journal ofGeneral Internal Medicine, Rothberg et al. present a largeanalysis of VTE prophylaxis rates among medical patientsadmitted to 376 acute-care facilities in the United States,finding that a striking 64% of patients with at least a moderaterisk of VTE failed to receive VTE prophylaxis by the second dayof their hospitalization.9Using an administrative database of greater than 350,000medical inpatients with primary diagnoses indicating a mod-erate to high-risk of VTE, this study revealed not only overalllow rates of VTE prophylaxis, but also considerable variabilityin utilization rates across hospitals and providers. Despitesome differences in patient selection and definition of VTEprophylaxis, the low administration rates are consistent withother similar multi-institutional studies.6,10,11 A unique find-ing of the study was that, although prophylaxis rates variedamong individual physicians, physician practice seemed tocluster around institutional means. Patients with similar VTErisk profiles had widely divergent likelihoods of receiving VTEprophylaxis depending on the admitting hospital, with vari-ability observed by hospital size, type, and region. Thisvariation in clinical practice among hospitals suggests thatstrategies aimed at improving prophylaxis rates should bedirected at the institutional level.There are several limitations to this observational studyusing administrative data. One is the lack of information onclinical decision-making with regard to VTE prophylaxis, suchas contraindications to pharmacologic VTE prophylaxis orpatient preference. For example, a prior study found thatcontraindications excluded 10% of medical patients fromreceiving pharmacologic VTE prophylaxis.6 It was possible thatsome services may not have been consistently or uniformlycaptured, as they were dependent on accurate billing andutilization codes. Finally, using ICD-9 coded clinical diagnosesto classify patients into varying levels of VTE risk may besubject to misclassification and cannot completely capture theunique circumstances of individual patients, such as comfortcare or highly ambulatory individuals who were thought to beat low VTE risk.Nevertheless, even allowing that some patients in thisanalysis may not have required or desired VTE prophylaxis,the low administration rates in the study still suggest thatsignificant numbers of patients fail to receive appropriate VTEprophylaxis. That variation in prophylaxis administrationseemed to be more dependent on region and hospital practiceas opposed to individual patient factors highlights the need forcontinued study in system-wide and institutionally-directedinterventions. The direction of further research should nowfocus less on describing the scope of the problem and more onhow to best address barriers to quality improvement and mosteffectively implement solutions.STRATEGIES TO IMPROVE VTE PROPHYLAXISExpert panels, national quality organizations, and regulatorybodies have aligned to address VTE prevention. The JointCommission, the National Quality Forum, the Centers forMedicare & Medicaid Services, and the Agency for HealthcareResearch and Quality (AHRQ) have developed measure-basedinitiatives such as quality indicators, public reporting, andincentive and disincentive programs targeting VTE prophylaxisrates. These have provided the impetus for national collabora-tives such as the Society of Hospital Medicine (SHM) VTEPrevention Collaborative12 and the incorporation of VTEprophylaxis in the Surgical Care Improvement Project (SCIP).The Surgeon General issued a “Call to Action to Prevent DeepVenous Thrombosis and Pulmonary Embolism” in 2008,further emphasizing VTE prevention as a major public healthconcern.13 Despite efforts from leading regulatory and qualityimprovement agencies to promote awareness and motivationfor VTE prophylaxis, as well as clear evidence that the impactof VTE prevention efforts can be large, what seem to bestraightforward interventions are frequently challenging toimplement in actual practice.14The simplest but probably least effective strategy is attempt-ing to change practice through passive methods such as thePublished online February 14, 2010JGIM484development and publication of guidelines. Although guide-lines are vital in summarizing best practice recommendationsand expert opinion, even well-known guidelines, such as thoserecommending VTE prophylaxis, face multiple barriers interms of assimilation into clinical practice.9,15–17 The dissem-ination of locally specific recommendations can be moreeffective, particularly as part of a multipronged strategy.18More active strategies, such as targeted education aboutVTE prophylaxis,19 have shown effectiveness in improving VTEprophylaxis but are limited in reach and retention over time.Relying on individual clinicians to remember and applyinformation correctly at each clinical encounter is inefficientand frequently ineffective. An important area for furtherresearch should be directed in how to best implement ‘micro’level (i.e., at the point of care) interventions to assist providersat the time of the clinical encounter so as to encourage specificbehaviors. Examples of micro-level interventions that havebeen shown to improve VTE prophylaxis rates include auto-mated reminder systems such as computer alerts20 andprotocols embedded in admission and transfer order sets.20Computer alerts have been shown to improve VTE prophylaxisordering rates23,24 and were associated with a 41% reductionin the 90-day incidence of VTE in one study.20 Successfulstrategies acknowledge that clinical care is complex and fast-paced, and attempt to integrate interventions into usualclinical workflow. Interventions that embed VTE prophylaxisinto standardized, pre-existing order sets are more effectivethan asking physicians to complete separate, free-standingVTE-specific order sets.12 Simple interventions such as check-lists may also be effective, having been shown to dramaticallyimprove clinical outcomes in other settings such as reducingcatheter-related blood stream infections21, postoperative com-plications, and surgery-related deaths.22Enhancing clinical decision-support through building inreminder-systems and evidence-based recommendations intocomputerized order sets and electronic medical records, hasgreat potential.25 A 2005 meta-analysis of such systems foundimprovements in specific processes of care 62% of the time,though only 13% showed improved patient outcomes. Barriersto effective use included poor workflow integration, misalignedrelevance to patients at the point of care, and providerdisagreement with recommendations.25–27 Importantly, thevariability in uptake of computerized medical record systemsas well as the heterogeneity in decision-support capabilityacross specific institutions are barriers to widespread adoptionof this strategy at present.Measurement, through real time audit and feedback, is anessential component of any improvement strategy. Combiningaudit and feedback with other effective strategies such asreminder systems and decision support at the point of care, havebeen shown to improve VTE prophylaxis to near 100%.12However, there are numerous challenges in being able to collectdata in real time such that individual providers can respond toaudit and feedback. One such intervention, the use of a ‘qualitydashboard’ to provide summary reports of predetermined clinicalmeasures, is an example of a specific tool that can contribute tothe success of high performing institutions.28 Quality dash-boards can help hospital leadership guide the quality agenda,create accountability for high-priority measures29 and provideactionable information to effect change at the point-of-care.30Finally, catalyzing real improvement across institutionswould benefit from the adoption of general frameworks ofeffective quality improvement strategies. One example is theVTE Prevention Collaborative supported by the Society ofHospital Medicine, the Institute for Healthcare Improvement,and AHRQ.12 This collaborative seeks to disseminate effectivestrategies shown to improve VTE care as well as provideguidance and mentorship to individual hospitals at the locallevel to help address barriers to implementation12. By poolingknowledge and best practices, providing specific toolkits forquality improvement, and tailoring solutions to local insti-tutional culture, such initiatives help disseminate effectivesolutions and reduce duplication of efforts. Identifyingcharacteristics of high-performing institutions can providetemplates for other hospitals to model their efforts. Featuresof high-performing institutions include a culture that welcomesquality improvement and change, supports and retains individ-ual quality improvement “champions”, and institutional trans-parency and accountability.28CONCLUSIONSignificant numbers of hospitalized patients in the UnitedStates fail to receive appropriate VTE prophylaxis despite clearguidelines and widespread efforts to raise VTE awareness. Thestudy by Rothberg et al. highlights the magnitude andwidespread nature of the problem, as well as the widevariability in practice across different institutions9. Effortsshould now focus on disseminating effective strategies tochange clinical practice, both at the point of care andinstitutional level, and seek out high-performing institutionsas models of effective practice change.Open Access: This article is distributed under the terms of theCreative Commons Attribution Noncommercial License which per-mits any noncommercial use, distribution, and reproduction in anymedium, provided the original author(s) and source are credited.Corresponding Author: Diane Sliwka, MD; Division of HospitalMedicine, The University of California San Francisco, 533Parnassus Ave., Box 0131, San Francisco, CA 94143, USA(e-mail: dsliwka@medicine.ucsf.edu).REFERENCES1. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thrombo-embolism: The seventh ACCP conference on antithrombotic and throm-bolytic therapy. Chest. 2004;126(3 Suppl):338S–400S.2. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-basedperspective of the hospital incidence and case-fatality rates of deep veinthrombosis and pulmonary embolism. the worcester DVT study. ArchIntern Med. 1991;151(5):933–8.3. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolismrisk and prophylaxis in the acute hospital care setting (ENDORSEstudy): A multinational cross-sectional study. Lancet. 2008;371(9610):387–94.4. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venousthromboembolism: American college of chest physicians evidence-basedclinical practice guidelines (8th edition). Chest. 2008;133(6Suppl):381S–453S.5. Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: Anticoagulant prophylaxis to prevent symptomatic venousthromboembolism in hospitalized medical patients. Ann Intern Med.2007;146(4):278–88.485Sliwka and Fang: Venous Thromboembolism Prophylaxis in the United StatesJGIM6. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolismrisk and prophylaxis in the acute hospital care setting (ENDORSEstudy): A multinational cross-sectional study. Lancet. 2008;371(9610):387–94.7. Tapson VF, Decousus H, Pini M, et al. Venous thromboembolismprophylaxis in acutely ill hospitalized medical patients: Findings fromthe international medical prevention registry on venous thromboembo-lism. Chest. 2007;132(3):936–45.8. Goldhaber SZ, Tapson VF, Steering Committee. A prospective registryof 5, 451 patients with ultrasound-confirmed deep vein thrombosis. AmJ Cardiol. 2004;93(2):259–62.9. Rothberg MB, Lahti M, Pekow PS, Lindenauer PK. Venous thrombo-embolism prophylaxis among medical patients at US hospitals. J GenIntern Med. 2010.10. Amin A, Stemkowski S, Lin J, Yang G. Thromboprophylaxis rates in USmedical centers: Success or failure? J Thromb Haemost. 2007;5(8):1610–6.11. Amin AN, Stemkowski S, Lin J, Yang G. Inpatient thromboprophylaxisuse in U.S. hospitals: Adherence to the seventh american college of chestphysician’s recommendations for at-risk medical and surgical patients. JHosp Med. 2009;4(8):E15–21.12. Maynard G, Stein J. Designing and implementing effective venousthromboembolism prevention protocols: Lessons from collaborativeefforts. J Thromb Thrombolysis. 2010;29(2):159–66.13. Galson SK. The surgeon general’s call for action to prevent deep venousthrombosis and pulmonary embolism. 2008;2010(2 24 2010).14. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies oncompliance with hand hygiene guidelines in hospital care. Infect ControlHosp Epidemiol. 2010;31(3):283–94.15. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians followclinical practice guidelines? A framework for improvement. JAMA.1999;282(15):1458–65.16. Cohn SL. Prophylaxis of venous thromboembolism in the US: Improvinghospital performance. J Thromb Haemost. 2009;7(9):1437–45.17. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, HannahWJ.Dopractice guidelines guide practice? the effect of a consensus statementon the practice of physicians. N Engl J Med. 1989;321(19):1306–11.18. Peterson GM, Drake CI, Jupe DM, Vial JH, Wilkinson S. Educationalcampaign to improve the prevention of postoperative venous thrombo-embolism. J Clin Pharm Ther. 1999;24(4):279–87.19. Michota FA. Bridging the gap between evidence and practice in venousthromboembolism prophylaxis: The quality improvement process. J GenIntern Med. 2007;22(12):1762–70.20. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venousthromboembolism among hospitalized patients. N Engl J Med. 2005;352(10):969–77.21. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. N Engl JMed. 2006;355(26):2725–32.22. Haynes AB, Weiser TG, Berry WR, et al. 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A clinical decision support system for prevention of venous thromboembolism: Effect on physician behavior.

A computerized reminder system to increase the use of preventive care for hospitalized patients.

A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. the worcester DVT study. Arch Intern Med.

A surgical safety checklist to reduce morbidity and mortality in a global population.

An intervention to decrease catheter-related bloodstream infections in the ICU.

Bridging the gap between evidence and practice in venous thromboembolism prophylaxis: The quality improvement process.

Computer-based clinical decision aids. A review of methods and assessment of systems.

Designing and implementing effective venous thromboembolism prevention protocols: Lessons from collaborative efforts.

Do practice guidelines guide practice? the effect of a consensus statement on the practice of physicians.

Educational campaign to improve the prevention of postoperative venous thromboembolism.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review.

Electronic alerts to prevent venous thromboembolism among hospitalized patients.

Hospital boards and quality dashboards.

Hospital quality: Ingredients for success overview and lessons learned. The Commonwealth Fund.

Inpatient thromboprophylaxis use in U.S. hospitals: Adherence to the seventh american college of chest physician’s recommendations for at-risk medical and surgical patients.

Metaanalysis: Anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients.

Prevention of venous thromboembolism:

Prevention of venous thromboembolism: American college of chest physicians evidence-based clinical practice guidelines (8th edition).

Prophylaxis of venous thromboembolism in the US: Improving hospital performance.

Situational awareness improves prevalence of VTE prophylaxis on multiple nursing units.

Smart forms” in an electronic medical record: Documentation-based clinical decision support to improve disease management.

Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol.

Tapson VF, Steering Committee. A prospective registry of 5, 451 patients with ultrasound-confirmed deep vein thrombosis.

The surgeon general’s call for action to prevent deep venous thrombosis and pulmonary embolism.

Thromboprophylaxis rates in US medical centers: Success or failure? J Thromb Haemost.

Venous thromboembolism prophylaxis among medical patients at US hospitals.

Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: Findings from the international medical prevention registry on venous thromboembolism.

Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study.

Why don’t physicians follow clinical practice guidelines? A framework for improvement.

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Venous Thromboembolism Prophylaxis in the United States: Still Room for Improvement

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