Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach.

BACKGROUND: While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. OBJECTIVE: We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. DESIGNS, SETTINGS AND PARTICIPANTS: A quality improvement initiative was implemented across 11 safety net hospitals in New York City. INTERVENTION: The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. RESULTS: Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.

Analysis of Factors Potentially Influencing Diagnostic Yield Among Computed Tomography-Guided Biopsies for Bone Lesions.

OBJECTIVE: This study aimed to investigate patient-specific, lesion-related, and technical factors that potentially influence diagnostic yield of computed tomography (CT)-guided biopsies of bone lesions. METHODS: Computed tomography-guided bone lesion biopsies performed over a 2-year period were retrospectively reviewed, including image review and electronic medical records for pathology reports and clinical follow-up. Lesions were tabulated by prebiopsy CT and magnetic resonance imaging features. Patients with nondiagnostic biopsies were assessed for presumptive clinical diagnosis and management. RESULTS: Nondiagnostic pathology results were obtained in 31 of 156 cases (19.87%), among which diagnoses were confirmed by other tissue sampling in 9; clinical follow-up of up to 2 years yielded no diagnosis in 10 and presumptive diagnoses in 12. The nondiagnostic biopsy rate of long bone lesions was higher than that of other bone lesions (odds ratio, 3.46; 95% confidence interval, 1.32-9.09). There were no significant differences in patient American Society of Anesthesiologists class, mean body mass index, sedation method, number of cores, or needle gauge between diagnostic and nondiagnostic biopsy cohorts. Diagnostic yield was not significantly different between occult, lytic, or sclerotic lesions. There was no difference in diagnostic yield regarding presence of cortical break, gadolinium enhancement, or lesion depth. Magnetic resonance imaging was obtained before biopsy in significantly more nondiagnostic cases compared with diagnostic cases ( P = 0.027). CONCLUSIONS: Computed tomography-guided biopsies had a nondiagnostic rate of 19.87%, and lesions in the long bones of the extremities were disproportionately common among this group. There was no significant association between biopsy results and several patient-specific, lesion-related, and technical factors.