Venous Thromboembolism Prophylaxis in Hospitalized Adult Patients: A Multidisciplinary Approach

 


Release Date: June 29, 2018
Expiration Date: June 29, 2019
Media: Internet - based

Activity Overview

This Community Practice Connections™ focuses on multidisciplinary approaches for the prophylaxis of venous thromboembolism (VTE) in hospitalized adult patients. VTE, which can take the form of deep vein thrombosis and/or pulmonary embolism, affects approximately 900,000 Americans each year and leads to death in approximately 100,000 Americans annually. In addition to the morbidity and mortality, VTE is associated with substantial health care costs. Under-prescribing for VTE prophylaxis may exacerbate the issue. Keeping health care providers apprised of current guidelines and therapies for VTE prophylaxis can improve patient outcomes.

This activity features video interviews with 2 leading cardiologists who discuss VTE risks and guideline recommendations for VTE prevention in specific hospitalized patient populations as well as considerations for extended VTE prophylaxis. Updates from the 2018 American College of Cardiology meeting are shared along with key points that every practitioner should know about prophylaxis of VTE.

Acknowledgement of Commercial Support

This activity is supported by an independent educational grant from Portola Pharmaceuticals, Inc.
 

Instructions for This Activity and Receiving Credit

  • You will need to login to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “educational content/video files” will be available for your reference.
  • In order to receive a CME/CE certificate, participants must complete the activity.
  • Complete the posttest and pass with a score of 70% or higher, complete the evaluation and then click on request for credit. Participants may immediately download a CME/CE certificate upon completion of these steps.


Target Audience

This educational activity is intended for cardiologists, hematologists, hospitalists, residents, surgeons, anesthesiologists, and other hospital-based providers who care for patients with VTE.

Learning Objectives

At the conclusion of this activity,you should be better prepared to:

  • Explain the importance of multidisciplinary approaches to VTE prophylaxis
  • Identify the pathophysiological processes that underlie venous thromboembolism
  • Determine appropriate pharmacotherapy for VTE prophylaxis based on patient characteristics and drug properties

Faculty, Staff, and Planners’ Disclosures

Faculty

Geoffrey Barnes, MD, MSc
Assistant Professor of Internal Medicine
Frankel Cardiovascular Center
University of Michigan Medical School
Ann Arbor, Michigan
 
Disclosure: Grants/Research Support: Blue Cross Blue Shield of Michigan, Bristol-Myers Squibb, NHLBI, Pfizer; Consultant/Speakers Bureau: Bristol-Myers Squibb, Janssen, Pfizer, Portola
 
 
Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC
Executive Director of Interventional Cardiovascular Programs
Brigham and Women’s Hospital Heart & Vascular Center
Professor of Medicine, Harvard Medical School
Boston, Massachusetts
 
Disclosure: Grants/Research Support: Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood Pharmaceuticals, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi-Aventis, The Medicines Company
The staff of PER® have no relevant financial relationships with commercial interests to disclose.

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As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER® or any of the companies that provided commercial support for this activity
 

Accreditation/Credit Designation

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Physicians’ Education Resource®, LLC designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
 
Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing, Provider #16669, for 1.0 Contact Hours.

PER Pulse™ Recaps

1 of 3
VTE Risk Factors

Venous thromboembolism (VTE) is a serious condition with an incidence of approximately 123 cases per 100,000 person-years, which correlates to approximately 300,000 to 600,000 cases annually in the United States.1,2 In addition, mortality is very common in VTE, with death occurring in 10% to 30% of patients within 30 days.2 Many cases of VTE are avoidable , and the condition, affecting both surgical and medical patients, is one of the most common and preventable causes of hospital death.3,4 The 2008 surgeon general’s call to action for the prevention of VTE emphasized that the condition was classified as a medical error by the Institute of Medicine.5 The call to action also highlighted that prophylaxis is critical for improving patient safety.5 The medical community responded with a range of efforts, including epidemiology studies, clinical research, and clinical recommendations. Through these efforts, the understanding of VTE risk factors and effective prevention and treatment strategies have improved.

One of the first steps in preventing VTE is for clinicians to consider and understand the risk factors. The classic example of Virchow’s triad of thrombosis, which describes the interplay between vascular injury, blood stasis, and hypercoagulability, remains valid as a foundational explanation of thrombosis in general.6,7 Subsequently, a range of VTE risk factors have been identified.8,9 These include:

  • Increasing age
  • Family history of VTE
  • Recent major surgery
  • Recent or current hospitalization for acute medical illness
  • Trauma/fracture
  • Increased plasma D-dimer
  • Active cancer
  • Active gastroduodenal ulcer
  • Renal failure
  • Rheumatic disease
  • Hepatic failure

Risk Assessment Models
Codifying risk factors takes the form of risk assessment models (RAMs), which clinicians can use to assist their decision making. Validated RAMs can be converted to convenient checklists or other types of forms to guide appropriate prophylactic regimens.10 The RAMs can be classified based on the type of patient, surgical or medical. Commonly used RAMs include:

  • Surgical patients
    • Caprini11
    • Rogers12
  • Medical patients
    • Padua Prediction Score13
    • IMPROVE14
    • IMPROVEDD15

Clinical research continues to elucidate the pathophysiology of VTE as well as appropriate preventive and therapeutic approaches. Future directions in VTE prevention and treatment may focus on the fundamental processes driving thrombosis. One prevailing theory posits that inflammation is the underlying pathology of VTE.16 Evidence supporting this theory includes the common inflammatory risk factors for both atherosclerosis and VTE, the results of the JUPITER trial (43% reduction in the rate of VTE in patients with elevated C-reactive protein), and the increased risk of VTE in patients with chronic inflammatory disorders.17

Deepak Bhatt, MD, MPH, executive director of interventional cardiovascular services at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, both in Boston, Massachusetts, summarized the interplay among VTE, atherosclerosis, and inflammation: “What many of us learned in medical school is that there’s the arterial side of the world and the venous side of the world. There’s some truth to that, obviously, but a lot of patients at risk for venous thromboembolic disease are also having or at risk for atherosclerosis and vice versa. It really is important to screen patients globally for their cardiovascular risk, not focusing only on the arterial or venous side but rather focusing on both. There are many common risk factors. Biologically speaking, it turns out that inflammation appears to be a shared risk factor for arterial and venous thrombotic events. That is a very exciting scientific discovery [in] just the past few years.”

With the pace of clinical discovery, staying current on VTE risk factors, VTE RAMs, and the basic science of VTE will promote better understanding of the condition and aid in the development of effective preventive strategies.

References
  1. Heit JA, Crusan DJ, Ashrani AA, Petterson TM, Bailey KR. Effect of a near-universal hospitalization-based prophylaxis regimen on annual number of venous thromboembolism events in the US. Blood. 2017;130(2):109-114. doi: 10.1182/blood-2016-12-758995.
  2. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(suppl 4):S495-S501. doi: 10.1016/j.amepre.2009.12.017.
  3. Maynard G. Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. Rockville, MD: Agency for Healthcare Research and Quality; 2016. AHRQ publication 16-0001-EF.
    ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf. Published August 2016. Accessed April 15, 2018.
  4. Centers for Disease Control and Prevention (CDC). Venous thromboembolism in adult hospitalizations - United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012;61(22):401-404.
  5. Office of the Surgeon General; National Heart, Lung, and Blood Institute. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville, MD: Office of the Surgeon General; 2008. ncbi.nlm.nih.gov/pubmed/20669525. September 15, 2008. Accessed March 8, 2018.
  6. Kumar DR, Hanlin E, Glurich I, Mazza JJ, Yale SH. Virchow’s contribution to the understanding of thrombosis and cellular biology. Clin Med Res. 2010;8(3-4):168-172. doi: 10.3121/cmr.2009.866.
  7. Watson T, Shantsila E, Lip GY. Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet. 2009;373(9658):155-166. doi: 10.1016/S0140-6736(09)60040-4.
  8. Decousus H, Tapson VF, Bergmann J-F, et al; IMPROVE Investigators. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139(1):69-79. doi: 10.1378/chest.09-3081.
  9. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016;41(1):3-14. doi: 10.1007/s11239-015-1311-6.
  10. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA Jr, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2):344-350. doi: 10.1097/SLA.0b013e3181b7fca6.
  11. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2-3):70-78. doi: 10.1016/j.disamonth.2005.02.003.
  12. Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1211-1221. doi: 10.1016/j.jamcollsurg.2007.02.072.
  13. Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010;8(11):2450-2457. doi: 10.1111/j.1538-7836.2010.04044.x.
  14. Spyropoulos AC, Anderson FA, FitzGerald G, et al; IMPROVE Investigators. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011;140(3):706-714. doi: 10.1378/chest.10-1944.
  15. Gibson C, Spyropoulos A, Cohen A, et al. The IMPROVEDD VTE risk score: incorporation of D-dimer into the IMPROVE score to improve venous thromboembolism risk stratification. TH Open. 2017;01(01):e56-e65. doi: 10.1055/s-0037-1603929.
  16. Piazza G, Ridker PM. Is venous thromboembolism a chronic inflammatory disease? Clin Chem. 2015;61(2):313-316. doi: 10.1373/clinchem.2014.234088.
  17. Piazza G, Goldhaber SZ. Venous thromboembolism and atherothrombosis: an integrated approach. Circulation. 2010;121(19):2146-2150. doi: 10.1161/CIRCULATIONAHA.110.951236.

2 of 3
Important Points to Consider With VTE Prophylaxis

Prophylactic measures are effective in preventing venous thromboembolism (VTE) in at-risk patients. The decision about which prophylactic approaches to use is based on patient characteristics. Guidelines for the prophylaxis of VTE include those published by the American College of Chest Physicians.1 In those guidelines, suggested prophylaxes are specified based on detailed patient characteristics.2-4

Although the guidelines are detailed and comprehensive, clinicians should also keep in mind additional points when caring for patients who are at risk for VTE. A first step in addressing the issue of VTE is to be aware that certain patients are at risk. Deepak Bhatt, MD, MPH, executive director of interventional cardiovascular services at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, both in Boston, Massachusetts, said, “Historically, I think there’s been pretty good awareness that surgical patients are at risk, but more recently [there has been] awareness that acutely medically ill patients are also at risk of VTE.” He added, “It can be someone that is medically sick and in the hospital for heart failure, pneumonia, any number of things. Just be aware that the risk is in all patients that are potentially hospitalized or going to be sedentary, say, after a procedure or while waiting for it.”

Risk stratification is another point to consider in VTE prophylaxis. By using validated risk assessment models (eg, Caprini,5 Rogers,6 Padua,7 IMPROVE,8 IMPROVEDD9), clinicians can identify and stratify a patient’s level of risk for VTE.10,11 Patients at higher risk for VTE would be recommended for prophylactic measures, whereas patients at low risk may not require such intervention. Those patients at low risk avoid potential adverse effects, particularly bleeding complications, from the pharmacologic agents used in prophylaxis. Research supports risk stratification in the effective prevention of VTE, particularly in patients at the highest risk levels.10-12 In addition, lack of adherence to risk stratification guidelines may lead to overuse of anticoagulants.13 Geoffrey Barnes, MD, assistant professor of internal medicine at the Frankel Cardiovascular Center at the University of Michigan in Ann Arbor, emphasized that physicians need to risk-stratify patients. He stated, “Not everyone is going to need VTE prophylaxis. Use some sort of a well-designed validated risk stratification tool in your hospital.”

In recent years, the need for extended prophylaxis has become apparent.14-16 Supported by clinical trials such as EXCLAIM,17 MAGELLAN,18 and APEX,19 among others, extended prophylaxis should be considered in appropriate patient populations. Drs Bhatt and Barnes share the perspective that at-risk patients may benefit from extended prophylaxis. Dr Bhatt explained that physicians should understand that VTE risk is not limited to the time of hospitalization. “But that risk persists because there’s an underlying substrate in that patient that is predisposing them to thrombotic events,” Dr Bhatt stated. “Therefore, the approaches to prevent venous thromboembolic events can’t focus just on that immediate periprocedural hospitalization period, but their concern for risk needs to extend beyond that, potentially [for] the duration of therapy.”

Dr Barnes emphasized that some such patients, including critically ill medical patients, will need prophylaxis beyond the hospital stay for proper care. “Using some risk stratification tools like age, like [the] reason they were hospitalized, to help figure out who is going to need additional prophylactic therapy is really important,” he added.

Prophylactic measures are essential for countering the potential of patients developing VTE. Thinking beyond practice guidelines can help clinicians provide optimal care to at-risk patients in both the medical and surgical realms.

References
  1. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):7S-47S. doi:10.1378/chest.1412S3.
  2. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):e278S-e325S. doi: 10.1378/chest.11-2404.
  3. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines, Chest. 2012;141(suppl 2):e227S-e277S. doi: 10.1378/chest.11-2297.
  4. Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):e195S-e226S. doi: 10.1378/chest.11-2296.
  5. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2-3):70-78. doi: 10.1016/j.disamonth.2005.02.003.
  6. Rogers SO, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1211-1221. doi: 10.1016/j.jamcollsurg.2007.02.072.
  7. Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010;8(11):2450-2457. doi: 10.1111/j.1538-7836.2010.04044.x.
  8. Spyropoulos AC, Anderson FA, FitzGerald G, et al; IMPROVE Investigators. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011;140(3):706-714. doi: 10.1378/chest.10-1944.
  9. Gibson C, Spyropoulos A, Cohen A, et al. The IMPROVEDD VTE risk score: incorporation of D-dimer into the IMPROVE score to improve venous thromboembolism risk stratification. TH Open. 2017;01(01):e56-e65. doi: 10.1055/s-0037-1603929.
  10. Turrentine FE, Sohn M-W, Wilson SL, et al. Fewer thromboembolic events after implementation of a venous thromboembolism risk stratification tool. J Surg Res. 2018;225:148-156. doi: 10.1016/j.jss.2018.01.013.
  11. Pannucci CJ, Obi A, Alvarez R, et al. Inadequate venous thromboembolism risk stratification predicts venous thromboembolic events in surgical intensive care unit patients. J Am Coll Surg. 2014;218(5):898-904. doi: 10.1016/j.jamcollsurg.2014.01.046.
  12. Pannucci CJ, Swistun L, MacDonald JK, Henke PK, Brooke BS. Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients. Ann Surg. 2017;265(6):1094-1103. doi: 10.1097/SLA.0000000000002126.
  13. Pavon JM, Sloane RJ, Pieper CF, et al. Poor adherence to risk stratification guidelines results in overuse of venous thromboembolism prophylaxis in hospitalized older adults. J Hosp Med. 2018;13(6):403-404. doi: 10.12788/jhm.2916.
  14. Liew AYL, Piran S, Eikelboom JW, Douketis JD. Extended-duration versus short-duration pharmacological thromboprophylaxis in acutely Ill hospitalized medical patients: a systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis. 2017;43(3):291-301. doi: 10.1007/s11239-016-1461-1.
  15. Mahan CE, Burnett AE, Fletcher ML, Spyropoulos AC. Extended thromboprophylaxis in the acutely ill medical patient after hospitalization – a paradigm shift in post-discharge thromboprophylaxis. Hosp Pract (1995). 2018;46(1):5-15. doi: 10.1080/21548331.2018.1410053.
  16. Chan NC, Gross PL, Weitz JI. Addressing the burden of hospital-related venous thromboembolism: the role of extended anticoagulant prophylaxis. J Thromb Haemost. 2018;16(3):413-417. doi: 10.1111/jth.13942.
  17. Hull RD, Schellong SM, Tapson VF, et al; EXCLAIM (Extended Prophylaxis for Venous ThromboEmbolism in Acutely Ill Medical Patients With Prolonged Immobilization) study. Extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility. Ann Intern Med. 2010;153(1):8-18. doi: 10.7326/0003-4819-153-1-201007060-00004.
  18. Cohen AT, Spiro TE, Büller HR, et al; MAGELLAN Investigators. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med. 2013;368(6):513-523. doi: 10.1056/NEJMoa1111096.
  19. Cohen AT, Harrington RA, Goldhaber SZ, et al; APEX Investigators. Extended thromboprophylaxis with betrixaban in acutely ill medical patients. N Engl J Med. 2016;375(6):534-544. doi: 10.1056/NEJMoa1601747.

3 of 3
Effective Multidisciplinary Approaches

Healthcare systems rely on coordinated efforts of multiple disciplines to deliver optimal healthcare, reduce medical errors, and improve patient outcomes.1 Recognizing the importance of teamwork across disciplines, the Institute of Medicine has emphasized the importance of interprofessional efforts in health professional education.2 Such multidisciplinary efforts are necessary in part because of the complexities of healthcare systems and the complexities of disease states. Venous thromboembolism (VTE) is a complex disorder with multiple factors that predispose a patient to the disease.3 Many cases of VTE are preventable, and both surgical and medical patients are affected.4,5 Addressing VTE prophylaxis from multiple disciplines, therefore, can make prevention efforts more effective.6-11

The Centers for Medicare & Medicaid Services and the Joint Commission collaborate on performance and quality measures, including measures to incentivize hospitals to focus on VTE prevention efforts.12-14 Successful approaches to reinforce and institutionalize VTE prophylaxis measures include those that rely on multidisciplinary tactics.6-10 Key personnel include nurses, nurse practitioners, physician assistants, and pharmacists. As Geoffrey Barnes, MD, assistant professor of internal medicine at the Frankel Cardiovascular Center at the University of Michigan in Ann Arbor, described, “I think one of the most important things is to make sure that everyone at your institution is on the same page. That means having representation from…surgeons, medicine specialists, cardiologists, pharmacists. [It means] bringing people together in some type of a VTE committee or an anticoagulation pharmacy and therapeutics committee so that you can set up guidelines and then come up with treatment algorithms and plans that automate how physicians and nurse practitioners— physician assistants—how they’re going to care for patients.”

Besides healthcare practitioners, the patient can be an integral part of the process, and current guidelines of the American College of Chest Physicians emphasize patient preferences.15,16 Dr Barnes added, “It’s also really helpful to have some patient representatives on that team so that you can hear from their perspective what [it is] that they are seeing, what education do they need, how are their preferences going to play into that decision-making process. I think it’s important that they’re all a part of the team and that you’re looking at the care across the continuum.”

Although each member of the healthcare team is important for patient success, the roles of pharmacists in VTE prophylaxis is critical, particularly with the range of available pharmacologic agents. VTE prophylaxis and treatment efforts led by pharmacists, including anticoagulation clinics, can promote positive patient outcomes.8,17-19 Dr Barnes emphasized the impact of pharmacists when he stated, “Pharmacists are really important team members when we come to treating patients with venous thromboembolism. In our hospital, for instance, our pharmacists review all patients who are receiving anticoagulants, whether it’s oral anticoagulants or parenteral anticoagulants such as heparin and low molecular weight heparin. They help with dose titration. They help to make sure that we prescribe the right drug, that it’s safe. They screen for drug–drug interactions. They’re really important team members.”

As a preventable cause of hospital-associated mortality and morbidity, VTE requires coordinated measures to implement prophylactic regimens that reduce patient risk. Pharmacists can play critical roles in VTE prophylaxis, particularly in managing drug therapies.

References
  1. Mao AT, Woolley AW. Teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication. AMA J Ethics. 2016;18(9):933-940. doi: 10.1001/journalofethics.2016.18.9.stas2-1609.
  2. IOM (Institute of Medicine). Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Washington, DC: The National Academies Press; 2015.
    https://www.nap.edu/catalog/21726/measuring-the-impact-of-interprofessional-education-on-collaborative-practice-and-patient-outcomes. Accessed April 15, 2019. doi: 10.17226/21726.
  3. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 16;41(1):3-14. doi: 10.1007/s11239-015-1311-6.
  4. Maynard G. Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. Rockville, MD: Agency for Healthcare Research and Quality; 2016. AHRQ publication 16-0001-EF.
    ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf. Accessed April 15, 2018.
  5. Centers for Disease Control and Prevention (CDC). Venous thromboembolism in adult hospitalizations - United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012;61(22):401-404. ncbi.nlm.nih.gov/pubmed/22672974. Accessed July 3, 2018.
  6. Pingleton SK, Carlton E, Wilkinson S, et al. Reduction of venous thromboembolism (vte) in hospitalized patients. Acad Med. 2013;88(10):1454-1459. doi: 10.1097/ACM.0b013e3182a4aa51.
  7. Schleyer AM, Robinson E, Dumitru R, et al. Preventing hospital-acquired venous thromboembolism: improving patient safety with interdisciplinary teamwork, quality improvement analytics, and data transparency. J Hosp Med. 2016;11(suppl 2):S38-S43. doi: 10.1002/jhm.2664.
  8. Streiff MB, Lau BD, Hobson DB, et al. The Johns Hopkins Venous Thromboembolism Collaborative: multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med. 2016;11(suppl 2):S8-S14. doi: 10.1002/jhm.2657.
  9. Duff J, Omari A, Middleton S, McInnes E, Walker K. Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study. BMC Health Serv Res. 2013;13(1):398. doi: 10.1186/1472-6963-13-398.
  10. Cardoso LF, Krokoscz DVC, de Paiva EF, et al. Results of a venous thromboembolism prophylaxis program for hospitalized patients. Vasc Health Risk Manag. 2016;12:491-496. doi: 10.2147/VHRM.S101880.
  11. Barnes GD, Birkmeyer N, Flanders SA, et al. Venous thromboembolism: a collaborative quality improvement model for practitioners, hospitals, and insurers. J Thromb Thrombolysis. 2012;33(3):274-279. doi: 10.1007/s11239-012-0699-5.
  12. Gidwani R, Bhattacharya J. CMS reimbursement reform and the incidence of hospital-acquired pulmonary embolism or deep vein thrombosis. J Gen Intern Med. 2015;30(5):588-596. doi: 10.1007/s11606-014-3087-3.
  13. Venous thromboembolism. The Joint Commission website. jointcommission.org/venous_thromboembolism. Accessed July 5, 2018.
  14. eCQMs. eCQI Resource Center website. ecqi.healthit.gov/ecqms. Updated January 24, 2019. Accessed July 5, 2018.
  15. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):7S-47S. doi: 10.1378/chest.1412S3.
  16. Wong A, Kraus PS, Lau BD, et al. Patient preferences regarding pharmacologic venous thromboembolism prophylaxis. J Hosp Med. 2015;10(2):108-111. doi: 10.1002/jhm.2282.
  17. Bauer JB, Chun DS, Karpinski TA. Pharmacist-led program to improve venous thromboembolism prophylaxis in a community hospital. Am J Health Syst Pharm. 2008;65(17):1643-1647. doi: 10.2146/ajhp070595.
  18. DiRenzo BM, Beam DM, Kline JA, et al. Implementation and preliminary clinical outcomes of a pharmacist-managed venous thromboembolism clinic for patients treated with rivaroxaban post emergency department discharge. Acad Emerg Med. 2018;25(6):634-640. doi: 10.1111/acem.13311.
  19. Lee EH, Bray V, Horne R. Developing an economic case of clinical pharmacists’ interventions on venous thromboembolism prophylaxis through service evaluation. J Res Pharm Pract. 2017;6(2):106-113. doi: 10.4103/jrpp.JRPP_16_160.

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