Where: Brigham and Women's Hospital, a 793-bed acute tertiary care facility in Boston.
The issue: Improving rates of venous thromboembolism (VTE) prophylaxis.
Even before 2008, when the U.S. Surgeon General identified pulmonary embolism as the most preventable cause of inpatient deaths, VTE prophylaxis was a focus of attention at Brigham and Women's. “We've done several projects trying to improve the prescription of prophylactic measures for patients in the hospital,” said cardiologist Gregory Piazza, MD, MS.
Despite these efforts, the hospital still had regular occurrences of VTE, even among patients who had received prescriptions for prophylaxis. A couple of years ago, Dr. Piazza and colleagues conducted a study among 250 patients to figure out why.
“We actually found that the most important reason for the patients not getting the ordered dose of prophylactic anticoagulation was patient refusal,” he said. “So we speculated that patients are not educated about why they need prophylactic anticoagulation in the hospital.”
To remedy this problem, Dr. Piazza's team developed a new patient education program.
How it works
In a recent trial of the program, more than 500 Brigham patients who needed anticoagulants received individualized education about the drugs from a research pharmacist. “The pharmacy department at Brigham and Women's Hospital has always had a very strong interest in medication safety and medication adherence. It seemed like a natural merger of mutual interests,” Dr. Piazza said.
The project was staffed by a single pharmacist who, working full-time, managed to see 99% of the patients within 24 hours of their prophylaxis prescriptions. “First the pharmacist had to learn about the patient, so she took about half an hour to understand why the patient was at increased risk for venous thromboembolism and to prepare teaching materials about the particular anticoagulant that the patient was receiving,” said Dr. Piazza. Actually meeting with and educating the patients took about 15 minutes per person, he added.
The program significantly improved uptake of prescribed prophylaxis, according to a comparison of the educated patients and a historical cohort published in the March American Journal of Medicine. “With this one-on-one patient education program, we improved medication adherence to almost 95%, which in our previous study we showed was under 90%,” said Dr. Piazza.
The effort also appeared to accomplish its primary goal—patient refusal was a much less common reason for patients not receiving their medications (44% in the historical cohort vs. 29% in the educated patients).
Money and time present major obstacles to widespread implementation of such a system. Bedside meetings with every patient receiving VTE prophylaxis would be time-consuming for hospital pharmacists. However, the Brigham researchers may have found a potential solution to this dilemma.
“One of the interesting things that we noticed was that we gave patients the opportunity to ask questions after the teaching portion of the patient education module. Very few patients—only about 3%—took advantage of the question-and-answer session,” said Dr. Piazza.
Given the rarity of questions, so much one-on-one time with the pharmacist might not be necessary, he speculated. “We still want to give patients the opportunity to ask questions if they have them, but we think that a hybrid patient education module that combines a computerized teaching program with some pre- and post-test questions would be more effective.”
Dr. Piazza and colleagues hope to develop and test such a model in a randomized, controlled trial. “If that's successful, I think this would be a very important adjunct to other (VTE) prevention initiatives hospitals may be undertaking,” he said.
Lack of education wasn't the only reason that patients declined prophylaxis, the researchers found. Their initial analysis of medication adherence showed that medication regimens mattered—once-daily therapy was less likely to be refused than injections given two or three times a day.
“Focusing on medications that are easier for patients to take is important,” said Dr. Piazza. “New anticoagulants that are oral may be ideal for prophylaxis.”