New Strategies for Preventing Pulmonary Embolism, DVT, and Stroke Pivotal Role of the Hospitalist in VTE and Stroke Prevention

Transcription

1 New Strategies for Preventing Pulmonary Embolism, DVT, and Stroke Pivotal Role of the Hospitalist in VTE and Stroke Prevention HMS Joseph B. Martin Conference Center Monday, November 27, 2017 Ebrahim Barkoudah, M.D., M.P.H., F.A.C.P, S.F.H.M. Associate Director Hospital Medicine Unit Brigham and Women s Hospital Associate Director - Global Education Instructor in Medicine - Harvard Medical School Disclosure: currently serving as a member of Clinical Endpoint Center, an academic research organization based at BWH that conducts clinical trials. These trials are funded by grants to BWH from both industry and the National Institutes of Health; received research grant support from the Research Foundation at BWH and lectures payment including educational talks. No direct relationships/conditions/circumstances that present a potential conflict of interest

2 Conflict of Interest Statement Grant/Research Support Amgen Novartis Janssen NIH Speakers Bureau Society of Hospital Medicine Medscape/theheart.org

3 Learning Objectives Apply the appropriate management of VTE prophylaxis to hospitalized patients. Describe the benefits and harms of VTE prophylaxis. Describe the role of the hospitalist in secondary stroke prevention.

4 Hospital Stays in the United States According to American Hospital Association and the Healthcare Cost and Utilization Project : Total Number of All U.S. Registered Hospitals 5,564 Total Staffed Beds in All U.S. Hospitals 897,961 with about 35,061,292 admissions annually An average length of stay of 4.5 days and an average cost of $10,400 per stay About 56 percent of hospital stays in 2012 were medical, 21.8 percent were surgical, and 22.2 percent were maternal or neonatal

5 The Recent Growth in Hospital Medicine Hospitalists role: Management of complex care Maintain a high quality practice in the era of precise medicine and accountable healthcare delivery Assurance of quality-of-care and proposing a new model for care delivery Wachter RM, et al. N Engl J Med. 2016; 375:1009. Barkoduah E. Hosp Med Clin. 2016;5:2.

6 Prophylaxis in Hospitalized Patients Assessment The importance of assessing individual patients' clinical profile Individualized assessment of risk factors Customize Many strategies that are available, but none of these risk assessment tools have been tested in terms of their reliability and validity Looking at the benefits and harms to conclude VTE prophylaxis may not be justified or beneficial Application The appropriate management of VTE prophylaxis in hospitalized patients Qaseem A, et al. Ann Intern Med. 2011;155:625

7 The Barriers for Best Practice 1 Lack of universal awareness 2 Gap between evidence and practice 4 Disseminating new information 4 Translating guidelines into meaningful use 5 Underestimation of the risk/benefit balance 6 Missing universal tools to assess the clinical risk in the real world 7 Use the knowledge in daily practice 8 Lack of system automation Multiple reasons have been invoked to explain under-utilization How can we preform better? Adapted from the Agency for Healthcare Research and Quality archives publication.

8 Quality dashboards and incentives QI initiatives to close the gap between guideline recommendations and clinical practice Hospital-wide education: educational in-services, materials, hospital roadshows Risk-assessment tools: simple, relevant and effective Electronic alerts Hospital Medicine Best Practice Computerized decision-support systems: based on structured clinical data and portfolio elements Audit and feedback mechanisms: taskforce and committees Michtalik HJ, et al. J Hosp Med. 2015;10: ; Merli G. Hospital Practice. 2010;38:7-16.

9 The Role of the Hospitalist in Daily Practice The role in VTE prophylaxis stewardship is essential During hospitalization, VTE prophylaxis, for those who are at risk, is the standard of care and presents evidence-based medicine in the clinical practice The hospitalist's role in applying the consensus and universal practice recommendation to guide the medical professional community regarding the optimal therapy The hospitalists' community and the frontline providers should be wellinformed regarding post-discharge VTE prophylaxis in medically ill patients This necessitates further efforts for clinicians' education and engagement, as well as a call for public awareness Khan SR, et al. Chest. 2012;141(suppl):e195S-e226S.

10 Preventing Recurrence of Thromboembolic Events Through Coordinated Treatment (PROTECT) Program Goals Role of the hospitalist in secondary stroke prevention care Initiation and maintenance of appropriate: Antithrombotic therapy Statin therapy Angiotensin-converting enzyme or angiotensin receptor blocker therapy Thiazide diuretic therapy Smoking-cessation advice and referral to a formal cessation program American Heart Association diet Exercise counseling Stroke education Ovbiagele B, et al. Neurology and Lu-Emerson C, et al. J Hosp Med. 2010

11 Hospital Medicine and the National Consensus Standards The Joint Commission and the National Quality Forum s endorsement of standardized VTE prophylaxis through reengineered electronic quality measures VTE prophylaxis, in its all forms, is integrated in the hospital inpatient department quality measures The role of the hospitalist clinicians to ensure the appropriate VTE prophylaxis application of the national consensus standards in policy, practices, and performance measures Michota FA, et al. J Gen Intern Med. 2007;22:

12 VTE Prophylaxis in Medical Patients Understand the epidemiology and prevalence of VTE Assess the risk/benefit Recognize the options of available strategies in VTE prevention Apply the current guidelines and practice standards Use these recommendations to improve daily practice Prevention of VTE in Medical Patients: Current Evidence and Recommendations: We should assess and then act on it

13 Process Map of VTE Prophylaxis The Hospitalist's Role Agency for Healthcare Research and Quality

14 Outcomes Chain for HA-VTE The Hospitalist s Role Agency for Healthcare Research and Quality

15 How To Improve Hospital Quality and Safety Assessing Readiness To Change Applying QIs to Your Hospital s Data Identifying Priorities for Quality Improvement Implementing Evidence-Based Strategies To Improve Clinical Care Monitoring Progress and Sustainability of Improvements Analyzing Return on Investment Quality Improvement Resources

16 More Efforts There WILL NOT be off-label and/or investigational discussion in this presentation.

17 And More Efforts

18 Stroke mortality a reasonable measure of stroke care quality Performance gap The Centers for Medicare & Medicaid Services acute ischemic stroke outcome measures Representation of hospital performance Joint Commission certified Primary Stroke Centers as the leaders in the field The goal is to improve patient care, compare institutions, as well as for rewarding or penalizing physicians through payments Stroke May;45(5):e96 Neurohospitalist. 2011; 1(2):

19 Role of the Hospitalist in Quality Improvement Efforts Create framework for curriculum development and QI principles for systems-based care in the hospital Lead hospital-based resources for care delivery Emphasize learning and feedback within each service/hospital Guide the impact the quality of the transition at discharge and subsequent patient outcomes Create platform for data collection and targeted prophylaxis decision support McKean S, et al. J Hosp Med. 2006;1:

20 Thank You