Interventions for increasing the use of thromboprophylaxis in hospitalized patients
Sübutlu məlumatların xülasələri
09.05.2018 • Sonuncu dəyişiklik 09.05.2018
Editors
Alerts appear to increase the use of appropriate thromboprophylaxis, and may decrease the rate of symptomatic venous thromboembolism at 3 months compared with standard care in hospitalized medical and surgical patients.
The quality of evidence is downgraded by study limitations (unclear allocation concealment).
Summary
A Cochrane review included 13 studies with a total of 35 997 subjects examing interventions to increase the use of measures to prevent the development of blood clots in hospitalized medical and surgical patients.
Alerts were associated with an increase in the proportion of participants who received prophylaxis (RD 21%, 95% CI 15% to 27%; 3 studies, n=5 057, statistical heterogeneity, I² = 75%) and who received appropriate prophylaxis (RD 16%, 95% CI 12% to 20%; 3 studies, n=1 820). Alerts were also associated with a reduction in the rate of symptomatic venous thromboembolism (VTE) at 3 months (RR 64%, 95% CI 47% to 86%; 3 studies, n=5 353). Computer alerts were associated with a reduction in the rate of symptomatic VTE, although there were not enough studies to pool computer alerts and human alerts results separately. Multifaceted interventions were associated with a small increase in the proportion of participants who received prophylaxis (cluster-adjusted RD 4%, 95% CI 2% to 6%; 5 studies, n=9 198). Multifaceted interventions with an alert component were found to be more effective than multifaceted interventions that did not include an alert.
RCTs: Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders and stickers on patient charts, increased the number of patients who received prophylaxis (risk difference (RD) 13%, 95% CI 1% to 25%). Two studies examining alerts reported venous thromboembolism (VTE) and safety outcomes. One study found a 41% reduction in the rate of all VTE, and a 60% reduction in the rate of pulmonary embolism (PE), both statistically significant. The other study found a 21% reduction in the rate of all VTE, 20% reduction in the rate of symptomatic deep venous thrombosis (DVT), and a 37% reduction in the rate of PE; however, no estimate was statistically significant. There were no significant effects on the rates of major bleeding, minor bleeding, or all cause mortality.
Non-randomized studies: Pooled RDs for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest effect. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Among the 3 non-randomized studies of alerts pooled to assess VTE, there was no significant reduction in DVT associated with an alert (RR 0.85, 95% CI 0.49 to 1.46). Two studies reported safety outcomes; one study found no difference in the rate of major bleeding, and the other study found no difference in the rate of minor bleeding but noted a significant 52% increase in the rate of all cause mortality.
Clinical comments
NoteThe review did not find a significant benefit for VTE outcomes; however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.
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Ədəbiyyat
- Kahn SR, Morrison DR, Diendéré G et al. Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database Syst Rev 2018;(4):CD008201. .