BACKGROUND/RATIONALE:
Venous thromboembolism (VTE), which comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE), is the most common preventable cause of hospital death. Veterans with cancer, and particularly those who undergo surgery are at particularly high risk with up to one-third of untreated patients (no
prophylaxis) developing deep venous thrombosis. Guidelines from the American College of Chest Physicians recommend prophylaxis throughout the hospital course and continuing post discharge for 4 weeks after surgery. Current hospital process measures (VA Surgical Quality Improvement Program-VASQIP VTE
measure, Joint Commission's Surgical Care Improvement Project SCIP-VTE-2) only examine prophylaxis during the procedure or in the 24 hours around the time of surgery rendering them inadequate in evaluating and promoting performance. Collaborative training modules from the Illinois Surgical Quality Improvement Collaborative (ISQIC) are available to raise awareness of VTE risk and prevention strategies among surgeons, surgical care teams, nurses and patients. We propose a VISN 12 directed evaluation to determine the effect of
VTE risk education modules on both inpatient and outpatient VTE prophylaxis.

OBJECTIVE(S):
We propose the following Specific Aims:

Aim 1: To determine whether multi-modal, provider-focused educational interventions can improve receipt of VTE inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis after major cancer surgery
in four VISN 12 hospitals.
H1: Scalable interventions for postoperative VTE prophylaxis can be effective in addressing local care barriers to receipt of inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis.

Aim 2: To identify patient and nursing provider perceptions of barriers to guideline-concordant care during the transition from inpatient to outpatient postsurgical VTE prophylaxis.
H1: Inpatient and post-discharge prophylaxis adherence is variable for Veterans after major cancer surgery due to lack of VTE risk awareness.

Aim 3: To perform a cost identification and budget impact analysis of increasing adherence to VTE prophylaxis guidelines.

METHODS:
Aim 1 methods will determine if provider-focused educational interventions can improve receipt of VTE inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis after major cancer surgery in VISN 12 hospitals.
The interventions will include the ISQIC VTE Bundle elements: Caprini risk assessment tools, audit/feedback of provider prescribing habits, risk awareness education for nurses and patients. Pre & Post intervention rate of missed doses of inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis for high risk surgical patients will be measured.

Aim 2 will use a mixed methods approach to determine factors associated with nurse and patient adherence to VTE prophylaxis guidelines.

Aim 3 will determine the budget impact of improved compliance with VTE chemoprophylaxis after a provider-focused behavioral intervention. All costs will be summarized and confidence intervals calculated.

FINDINGS/RESULTS:
None to date.

IMPACT:
This study will provide evidence on implementation of provider VTE risk education in a collaborative setting to encourage appropriate use of chemoprophylaxis.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002290-01A2
Link: https://reporter.nih.gov/project-details/9503555

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PUBLICATIONS:

Journal Articles

1. Merkow RP, Yang AD, Pavey E, Song MW, Chung JW, Bentrem DJ, Bilimoria KY. Comparison of Hospitals Affiliated With PPS-Exempt Cancer Centers, Other Hospitals Affiliated With NCI-Designated Cancer Centers, and Other Hospitals That Provide Cancer Care. JAMA internal medicine. 2019 Aug 1; 179(8):1043-1051. [view]
2. Ellis RJ, Ho JW, Schlick CJR, Merkow RP, Bentrem DJ, Bilimoria KY, Yang AD. National Use of Chemotherapy in Initial Management of Stage I Pancreatic Cancer and Failure to Perform Subsequent Resection. Annals of Surgical Oncology. 2020 Mar 1; 27(3):909-918. [view]
3. Castle J, Mazmudar A, Bentrem D. Preoperative coagulation abnormalities as a risk factor for adverse events after pancreas surgery. Journal of Surgical Oncology. 2018 May 1; 117(6):1305-1311. [view]
4. Ellis RJ, Brock Hewitt D, Liu JB, Cohen ME, Merkow RP, Bentrem DJ, Bilimoria KY, Yang AD. Preoperative risk evaluation for pancreatic fistula after pancreaticoduodenectomy. Journal of Surgical Oncology. 2019 Jun 1; 119(8):1128-1134. [view]
5. Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. Journal of Surgical Oncology. 2019 Jun 1; 119(7):925-931. [view]
6. Mazmudar A, Castle J, Yang AD, Bentrem DJ. The association of length of hospital stay with readmission after elective pancreatic resection. Journal of Surgical Oncology. 2018 Jul 1; 118(1):7-14. [view]
7. Ellis RJ, Zhang LM, Ko CY, Cohen ME, Bentrem DJ, Bilimoria KY, Yang AD, Talamonti MS, Merkow RP. Variation in Hospital Utilization of Minimally Invasive Distal Pancreatectomy for Localized Pancreatic Neoplasms. Journal of Gastrointestinal Surgery : Official Journal of The Society For Surgery of The Alimentary Tract. 2020 Dec 1; 24(12):2780-2788. [view]
8. Logan CD, Hudnall MT, Schlick CJR, French DD, Bartle B, Vitello D, Patel HD, Woldanski LM, Abbott DE, Merkow RP, Odell DD, Bentrem DJ. Venous Thromboembolism Chemoprophylaxis Adherence Rates After Major Cancer Surgery. JAMA Network Open. 2023 Sep 5; 6(9):e2335311. [view]

Journal Other

1. Ellis RJ, Zhang CY, Bentrem DJ, Bilimoria KY, Yang AD, Merkow RP. Minimally invasive distal pancreatectomy for pancreatic cystic neoplams and localized solid tumors: variation in utilization and potential as a quality measure. [Abstract]. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2019 Mar 1; 21(Supplement 1):S105-S106. [view]

DRA: Cancer, Cardiovascular Disease
DRE: Treatment - Observational, TRL - Applied/Translational
Keywords: Patient Safety, Provider Education, Symptom Management
MeSH Terms: none