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(Circulation. 2009;119:2196-2201.)
© 2009 American Heart Association, Inc.

Preventive Cardiology

Physician Alerts to Prevent Symptomatic Venous Thromboembolism in Hospitalized Patients

Gregory Piazza, MD; Erin J. Rosenbaum, BA; William Pendergast, MD; Joseph O. Jacobson, MD; Robert C. Pendleton, MD; Gordon D. McLaren, MD; C. Gregory Elliott, MD; Scott M. Stevens, MD; William F. Patton, MD; Ousama Dabbagh, MD; Marilyn D. Paterno, MBI; Elaine Catapane, MEd, MT; Zhongzhen Li, MD; Samuel Z. Goldhaber, MD

From the Cardiovascular Division, Department of Medicine (G.P., E.J.R., S.Z.G.), and Information Systems/Clinical Informatics Research and Development (M.D.P.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass; Department of Internal Medicine, The Washington Hospital, Washington, Pa (W.P.); Department of Medicine, North Shore Medical Center, Salem, Mass, and Harvard Medical School, Boston, Mass (J.O.J.); Department of Internal Medicine, University of Utah Health Sciences, Salt Lake City (R.C.P.); Department of Medicine, Intermountain Medical Center, Murray, Utah, and University of Utah School of Medicine, Salt Lake City (C.G.E., S.M.S.); Department of Veterans Affairs Long Beach Healthcare System, Long Beach, Calif, and Division of Hematology/Oncology, Department of Medicine, University of California, Irvine (G.D.M.); Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Mich (W.F.P.); Division of Pulmonary, Critical Care and Environmental Medicine, Department of Internal Medicine, University of Missouri–Columbia (O.D.); and Harvard Clinical Research Institute, Harvard University, Boston, Mass (E.C., Z.L.).

Correspondence to Gregory Piazza, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail gpiazza{at}partners.org

Received December 5, 2008; accepted February 17, 2009.

Background— Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis.

Methods and Results— We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis. We randomized 2493 patients (82% on Medical Services) from 25 study sites to the intervention group (n=1238), in which the responsible physician was alerted by another hospital staff member, or the control group (n=1255), in which no alert was issued. The primary end point was symptomatic, objectively confirmed VTE within 90 days. Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis as control subjects (46.0% versus 20.6%; P<0.0001). The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25), but the difference did not achieve statistical significance. The rate of major bleeding at 30 days in the alert group was similar to that in the control group (2.1% versus 2.3%; P=0.68).

Conclusions— A strategy of direct notification of the physician by a staff member increases prophylaxis use and leads to a reduction in the rate of symptomatic VTE in hospitalized patients. However, VTE prophylaxis continues to be underused even after physician notification, especially among Medical Service patients.

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CLINICAL PERSPECTIVE

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