Introduction: Venous Thromboembolism (VTE) is a potentially life-threatening disorder that may be provoked by venous stasis, endothelial injury or hypercoagulable states. Workups for hypercoagulable states are frequently undertaken, but tests performed are often either not indicated (if performed in older patients, provoked VTE) or uninterpretable ( if functional tests are ordered while patient anticoagulated or with active thrombus). Clinical decision support at point of order entry has the potential to prevent this unnecessary testing. As part of a larger QI project to improve care of VTE patients, we studied the impact of clinical decision support embedded in order sets, measuring the rates of appropriate hypercoagulable evaluations as a primary outcome.
Intervention: This study was undertaken from February 2013 - May 2015, and the effects of intervention were subsequently measured until May 2017. Hypercoagulable workups were defined as appropriate when ordered in patients who are < 45 years of age with unprovoked thrombus for all tests (gene and functional tests); and patients without active thrombi or anticoagulants for functional tests. A new order set was developed on the hospital health information system for VTE admissions. The order set provided evidenced-based guidance for ordering work-up. The order set was rolled out in April 2015, after extensive education of health care providers.
Outcome: Over the 2 years after the addition of the clinical decision support intervention, there was a reduction of the total number of hypercoagulable state work-ups from 21% pre-intervention to 15.7% post intervention, the average number of inappropriate tests reduced from 33 to 14 per month - a 57% reduction. Cost savings realized per month from the intervention was approximately $4,500 (pre-intervention: $9,050.73, post-intervention $4,569.98; P - 0.0004) and totaled about $117,000 over 26 months post intervention.
Conclusion: Clinical decision support interventions may result in a sustained decrease in unnecessary hypercoagulable workups.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.