Electronic Alerts to Prevent Venous Thromboembolism
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Computer reminders such as the one described by Kucher and colleagues (March 10 issue)1 can draw attention to important situations, since medical errors frequently occur when physicians are busy, tired, or distracted.2,3 The real challenge, however, is in developing programs that streamline care for physicians. If use of the program consumes time that would be better allocated elsewhere, it may simply shift the focus of a busy physician from one important area to another and thus simply shift the point at which errors are made. Therefore, more information on the program's ease of use would help readers determine its applicability and utility; such information might include a screen shot of the user interface, additional feedback from test subjects, statistics on the time required to use the program, and flow diagrams outlining where the program was used during a patient's admission and care process, who (e.g., interns, residents, or nurses) received alerts, and how many other kinds of alerts appeared on the Brigham and Women's Hospital computer system. Such information would help readers better ascertain how the program might affect a physician's workflow and whether it is a boon or a burden.
Bruce Y. Lee, M.D., M.B.A.
Esther H. Chen, M.D.
University of Pennsylvania
Philadelphia, PA 19104
brucelee@mail.med.upenn.edu
References
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005;352:969-977.
Altman DE, Clancy C, Blendon RJ. Improving patient safety -- five years after the IOM report. N Engl J Med 2004;351:2041-2043.
Volpp KGM, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med 2003;348:851-855.
To the Editor: Kucher et al. analyzed the effect of a computer-based reminder system designed to improve in-hospital thromboprophylaxis. The 90-day incidence of symptomatic venous thromboembolic events was high (4.0 percent, excluding events in the arms), and surprisingly, prophylaxis did not significantly reduce the incidence of venous thromboembolism. Among high-risk patients who have undergone hip arthroplasty and are given a week of prophylaxis, the 90-day incidence is 3.3 percent, and extending prophylaxis for 4 to 6 weeks is needed to lower the incidence significantly.1,2
In the study by Kucher et al., what was the mean length of hospitalization and the mean duration of in-hospital prophylaxis? Also, how did the authors adjust for or deal with the effect of rehospitalization (approximately 40 percent of the patients were rehospitalized) during the follow-up period?
Simply identifying high-risk medical patients and ordering subcutaneous heparin for a few days may not be effective. We need validated risk-stratification tools as well as clinical trials designed to determine whether short-duration, in-hospital prophylaxis reduces the incidence of symptomatic venous thromboembolism. The results of two studies indirectly suggest that a longer duration of thromboprophylaxis may be necessary in high-risk medical patients.3,4
Richard H. White, M.D.
Craig R. Keenan, M.D.
University of California, Davis
Sacramento, CA 95817
rhwhite@ucdavis.edu
Peter J. Kaboli, M.D.
Iowa City Veterans Affairs Medical Center
Iowa City, IA 52240
References
Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001;358:9-15.
White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000;343:1758-1764.
Leizorovicz A, Cohen AT, Turpie AG, Olsson CG, Vaitkus PT, Goldhaber SZ. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004;110:874-879.
Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. Lancet 1996;347:1357-1361.
The authors reply: Drs. Lee and Chen and Dr. White and colleagues can rest assured that electronic alerts are a boon to physicians and to patients, not a burden. Only 30 alerts were issued for every deep-vein thrombosis or pulmonary embolism that was prevented. The alerts were straightforward and user-friendly. The fear of increasing physicians' workload is not justified.
We caution Dr. White and colleagues about the pitfalls in comparing other populations composed of patients undergoing orthopedic surgery with our high-risk population, which consisted mostly of patients undergoing medical therapy (83 percent of the entire cohort). Our protocol was simple and yielded a powerful result: a 41 percent reduction in the three-month incidence of venous thromboembolism. Future studies should fine-tune the types of prophylaxis that are most beneficial and should clarify the optimal duration of prophylaxis.
Nils Kucher, M.D.
Samuel Z. Goldhaber, M.D.
Brigham and Women's Hospital
Boston, MA 02115
sgoldhaber@partners.org
Bruce Y. Lee, M.D., M.B.A.
Esther H. Chen, M.D.
University of Pennsylvania
Philadelphia, PA 19104
brucelee@mail.med.upenn.edu
References
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005;352:969-977.
Altman DE, Clancy C, Blendon RJ. Improving patient safety -- five years after the IOM report. N Engl J Med 2004;351:2041-2043.
Volpp KGM, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med 2003;348:851-855.
To the Editor: Kucher et al. analyzed the effect of a computer-based reminder system designed to improve in-hospital thromboprophylaxis. The 90-day incidence of symptomatic venous thromboembolic events was high (4.0 percent, excluding events in the arms), and surprisingly, prophylaxis did not significantly reduce the incidence of venous thromboembolism. Among high-risk patients who have undergone hip arthroplasty and are given a week of prophylaxis, the 90-day incidence is 3.3 percent, and extending prophylaxis for 4 to 6 weeks is needed to lower the incidence significantly.1,2
In the study by Kucher et al., what was the mean length of hospitalization and the mean duration of in-hospital prophylaxis? Also, how did the authors adjust for or deal with the effect of rehospitalization (approximately 40 percent of the patients were rehospitalized) during the follow-up period?
Simply identifying high-risk medical patients and ordering subcutaneous heparin for a few days may not be effective. We need validated risk-stratification tools as well as clinical trials designed to determine whether short-duration, in-hospital prophylaxis reduces the incidence of symptomatic venous thromboembolism. The results of two studies indirectly suggest that a longer duration of thromboprophylaxis may be necessary in high-risk medical patients.3,4
Richard H. White, M.D.
Craig R. Keenan, M.D.
University of California, Davis
Sacramento, CA 95817
rhwhite@ucdavis.edu
Peter J. Kaboli, M.D.
Iowa City Veterans Affairs Medical Center
Iowa City, IA 52240
References
Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001;358:9-15.
White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000;343:1758-1764.
Leizorovicz A, Cohen AT, Turpie AG, Olsson CG, Vaitkus PT, Goldhaber SZ. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004;110:874-879.
Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. Lancet 1996;347:1357-1361.
The authors reply: Drs. Lee and Chen and Dr. White and colleagues can rest assured that electronic alerts are a boon to physicians and to patients, not a burden. Only 30 alerts were issued for every deep-vein thrombosis or pulmonary embolism that was prevented. The alerts were straightforward and user-friendly. The fear of increasing physicians' workload is not justified.
We caution Dr. White and colleagues about the pitfalls in comparing other populations composed of patients undergoing orthopedic surgery with our high-risk population, which consisted mostly of patients undergoing medical therapy (83 percent of the entire cohort). Our protocol was simple and yielded a powerful result: a 41 percent reduction in the three-month incidence of venous thromboembolism. Future studies should fine-tune the types of prophylaxis that are most beneficial and should clarify the optimal duration of prophylaxis.
Nils Kucher, M.D.
Samuel Z. Goldhaber, M.D.
Brigham and Women's Hospital
Boston, MA 02115
sgoldhaber@partners.org