Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 1: Breast/Chest, Face, and Voice).

OBJECTIVE: To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA: Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to assess currently reported complication, satisfaction, and other outcome rates. RESULTS: Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. CONCLUSIONS: This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have assembled a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to high-quality research where improvement efforts should be focused.

Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction).

OBJECTIVE: To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA: Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress. METHODS: A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes. RESULTS: Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications. CONCLUSIONS: Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.

Effectiveness of Healthcare Delivery, Quality, and Safety a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex.

INTRODUCTION: Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS: We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS: Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS: Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.

Nonadministration of pharmacologic venous thromboembolism prophylaxis is less common in hospitalized patients with COVID-19.

INTRODUCTION: The incidence of venous thromboembolism (VTE) in patients hospitalized with COVID-19 is higher than most other hospitalized patients. Nonadministration of pharmacologic VTE prophylaxis is common and is associated with VTE events. Our objective was to determine whether nonadministration of pharmacologic VTE prophylaxis is more common in patients with COVID-19 versus other hospitalized patients. MATERIALS AND METHODS: In this retrospective cohort analysis of all adult patients discharged from the Johns hopkins hospital between Mar 1 and May 12, 2020, we compared demographic, clinical characteristics, VTE outcomes, prescription and administration of VTE prophylaxis between COVID-19 positive, negative, and not tested groups. RESULTS: Patients tested positive for COVID-19 were significantly older, and more likely to be Hispanic, have a higher median body mass index, have longer hospital length of stay, require mechanical ventilation, develop pulmonary embolism and die (all p < 0.001). COVID-19 patients were more likely to be prescribed (aOR 1.51, 95% CI 1.38-1.66) and receive all doses of prescribed pharmacologic VTE prophylaxis (aOR 1.48, 95% CI 1.36-1.62). The number of patients who missed at least one dose of VTE prophylaxis and developed VTE was similar between the three groups (p = 0.31). CONCLUSIONS: It is unlikely that high rates of VTE in COVID-19 are due to nonadministration of doses of pharmacologic prophylaxis. Hence, we should prioritize research into alternative approaches to optimizing VTE prevention in patients with COVID-19.

What Does Venous Thromboembolism Mean in the National Surgical Quality Improvement Program?

BACKGROUND: Venous thromboembolism (VTE) affects an estimated 350,000 to 600,000 individuals and causes approximately 100,000 deaths annually in the United States. Postoperative VTE is a core measure reported by The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP). The objective of this research was to assess the validity of VTE events reported by NSQIP. MATERIALS AND METHODS: This is a retrospective analysis using NSQIP data from January 2006 through December 2018 and the electronic health record system data from five adult hospitals in the Johns Hopkins Health System. We included patients aged 18 years and older with a VTE event identified in our NSQIP data set. The main outcome measure was the proportion of valid VTE events, defined as concordant between the NSQIP data set and medical chart review for clinical documentation. RESULTS: Of 474 patients identified in our NSQIP database with a VTE, 26 (5.5%) did not meet the strict NSQIP definition of VTE. Nine had a preoperative history of DVT and no new postoperative event, seven had a negative workup for VTE, six had a peripheral arterial thrombus, two did not receive or refused therapy, one had an aortic thrombus, and one had a venous thrombosis in a surgical flap. CONCLUSIONS: We identified a considerable number of surgical patients misclassified as having a VTE in NSQIP, when did not truly. This highlights the need to improve definition specificity and standardize processes involved in data extraction, validation, and reporting to provide unbiased data for use in quality improvement.

Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review.

A rise in antimicrobial resistance, seen especially since 2000, is in part caused by indiscriminate antimicrobial use. Varied types of persuasive interventions aimed to optimize antimicrobial use have been tried with varying success. Our review seeks to identify and assess factors associated with the successful implementation of persuasive interventions. We searched five databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, and ERIC) to identify critical studies published between 2000 and December 2018 of interventions employing audit and feedback, education through meetings, academic detailing, reminders, and patient, family, or public education. Outcome measures of interest were any means to measure antimicrobial use. We included 26 articles in our analysis. Seventeen examined multimodal interventions and the most common was audit and feedback and meeting (four studies). Nine examined single interventions and the most common was audit and feedback (five studies). Our findings inform four evidence-based strategies to enable healthcare administrators, clinicians, and researchers to make informed choices when planning and designing an antimicrobial stewardship program: (1) implement a combination of persuasive interventions from both groups: audit and feedback, academic detailing, or patient, family, or provider education; and meeting or reminders, (2) design interventions that last one year or longer; post-intervention, assess the intervention's long-term effects for at least another one year, (3) conduct quality improvement projects examining persuasive interventions if the prescribing database provides adequate diagnosis information, and most importantly, (4) make patient, family, or provider education an integral component of multimodal intervention.

Venous Thromboembolism Quality Measures Fail to Accurately Measure Quality.

Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients' risk for VTE and prescribe therapy appropriate for each patient's risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.

Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins.

BACKGROUND: Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery." METHODS: We evaluated the records of the medical archives of the Johns Hopkins University. RESULTS: We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic. CONCLUSION: This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

Collecting sexual orientation and gender identity information in the emergency department : the divide between patient and provider perspectives.

BACKGROUND: In the USA, The Joint Commission and Institute of Medicine have called for collection of patient sexual orientation (SO) and gender identity (GI) information in healthcare. In a recent study, we reported that ED clinicians believe patients will refuse to provide this information; however, very few patients say they would refuse to provide SO/GI. As part of this study, we interviewed patients and providers regarding the importance of collecting this information. While these interviews were briefly summarised in our prior report, the qualitative data warranted a more thorough analysis and exposition to explore provider and patient views as well as risks and benefits of collecting SO/GI. METHODS: A purposive sample of 79 participants was recruited for semi-structured interviews between August 2014 and January 2015. Participants included community members who had a previous ED encounter and ED providers from 3 community and 2 academic centres in a major US metropolitan area. Interviews were conducted one-on-one in person, audio-recorded and transcribed verbatim. Data were analysed using the constant comparative method. RESULTS: Fifty-three patients and 26 ED providers participated. Patients perceived collection of SO/GI to be important in most clinical circumstances because SO/GI is relevant to their identity and allows providers to treat the whole person. However, many providers felt SO/GI was not relevant in most clinical circumstances because similar care is provided to all patients regardless of SO/GI. Patients and providers agreed there are risks associated with collecting SO/GI in the ED. CONCLUSIONS: ED clinicians do not perceive routine collection of SO/GI to be medically relevant in most circumstances. However, patients feel routine SO/GI collection allows for recognition of individual identity and improved therapeutic relationships in the ED. These discordant perspectives may be hindering patient-centred care, especially for sexual and gender minority patients.

Narcotics reduction, quality and safety in gynecologic oncology surgery in the first year of enhanced recovery after surgery protocol implementation.

OBJECTIVES: Enhanced Recovery After Surgery (ERAS) programs are mechanisms for achieving value-based improvements in surgery. This report provides a detailed analysis of the impact of an ERAS program on patient outcomes as well as quality and safety measures during implementation on a gynecologic oncology service at a major academic medical center. METHODS: A retrospective review of gynecologic oncology patients undergoing elective laparotomy during the implementation phase of an ERAS program (January 2016 through December 2016) was performed. Patient demographics, surgical variables, postoperative outcomes, and adherence to core safety measures, including antimicrobial and venous thromboembolism (VTE) prophylaxis, were compared to a historical patient cohort (January 2015 through December 2015). Statistical analyses were performed using t-tests, Wilcoxon rank sum tests, and Chi squared tests. RESULTS: The inaugural 109 ERAS program participants were compared to a historical patient cohort (n=158). There was no difference in BMI, race, malignancy, or complexity of procedure between cohorts. ERAS patients required less narcotics (70.7 vs 127.4, p=0.007, oral morphine equivalents) and PCA use (32.1% vs. 50.6%, p=0.002). Despite this substantial reduction in narcotics, ERAS patients did not report more pain and in fact reported significantly less pain by postoperative day 3. There were no differences in length of stay (5days), complication rates (13.8% vs. 20.3%, p=0.17) or 30-day readmission rates (9.5 vs 11.9%, p=0.54) between ERAS and historical patients, respectively. Compliance with antimicrobial prophylaxis was 97.2%. However, 33.9% of ERAS patients received substandard preoperative VTE prophylaxis. CONCLUSIONS: ERAS program implementation resulted in reductions in narcotic requirements and PCA use without changes in length of stay or readmission rates. Compliance should be diligently audited during the implementation phase of ERAS programs, with special attention to adherence to pre-existing core safety measures.

Characterizing the relationship between age and venous thromboembolism in adult trauma patients: findings from the National Trauma Data Bank and the National Inpatient Sample.

BACKGROUND: Venous thromboembolism (VTE) is a tremendous burden in health care. However, current guidelines lack recommendations regarding the prevention of VTE in older adult trauma patients. Furthermore, the appropriate method of modeling of age in VTE models is currently unclear. METHODS: Patients included in the National Trauma Data Bank (NTDB) between the years 2008 and 2014 and patients included in the National Inpatient Sample (NIS) between 2009 and 2013 were analyzed. Multiple logistic regression of VTE on age was performed. RESULTS: Of 3,598,881 patients in the NTDB, 34,202 (1.0%) were diagnosed with VTE compared to 5405 (1.1%) of the 505,231 patients in NIS. In both the fully adjusted NTDB and NIS model, age was positively associated with odds of VTE diagnosis under 65 years (NTDB, adjusted odds ratio [aOR]: 1.018, 95% confidence interval [CI]: 1.017-1.019, P < 0.001; NIS, aOR: 1.025, 95% CI 1.022-1.027, P < 0.001). In patients aged ≥65 years, age was negatively associated with odds of VTE diagnosis in the NTDB (aOR: 0.995, 95% CI: 0.992-0.999, P = 0.006) but not in the NIS (aOR: 0.998, 95% CI 0.994-1.002, P = 0.26). CONCLUSIONS: Incidence of VTE among adult trauma patients steadily increases with age until 65 years, after which the odds of VTE appear to level off or even slightly decrease. These findings should be applied for improved modeling of VTE in trauma patients. The mechanism behind these findings should be explored before using them to update guidelines for standardized VTE prevention in older adults.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study.

OBJECTIVE: To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. BACKGROUND: Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. METHODS: This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013-2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. RESULTS: At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001). CONCLUSIONS: Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.

Beneficial "halo effects" of surgical resident performance feedback.

BACKGROUND: Venous thromboembolism (VTE) prevention is one of the most frequent measures of quality in hospital settings. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits for general surgical patients. The purpose of this study was to investigate the indirect, or "halo effects" of providing individualized performance feedback to residents regarding prescription of appropriate VTE prophylaxis. MATERIALS AND METHODS: This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 to May 31, 2015 at The Johns Hopkins Hospital, an academic hospital and Level 1 trauma center in Baltimore, Maryland. On October 1, 2013, we began providing monthly performance feedback to general surgery residents regarding their VTE prophylaxis prescribing habits for general surgery patients. Data were not provided about their prescription practice for trauma patients, or to any other prescribers within the hospital. RESULTS: During the study period, 931 adult trauma patients were admitted to the adult trauma service. After providing individualized feedback about general surgery patients, general surgery residents' prescribing practice for writing appropriate VTE prophylaxis orders for adult trauma patients significantly improved (93.9% versus 78.1%, P < 0.001). Prescription practice significantly improved among all other prescribers although they did not receive any specific individualized feedback, (84.9% versus 75.1%, P = 0.025); however, practice was significantly better among general surgery residents versus other providers (93.9% versus 84.9%, P = 0.003). CONCLUSIONS: There is a beneficial "halo effect" for patients treated by residents receiving individualized feedback about practice habits. Individualized feedback regarding practice habits for one patient type has both a direct and indirect effect on the quality of care patients receive and should be implemented for all providers.

Prescriber knowledge and attitudes regarding non-administration of prescribed pharmacologic venous thromboembolism prophylaxis.

Pharmacologic venous thromboembolism (VTE) prophylaxis is important patient safety practice in hospitalized patients. However, a substantial number of ordered doses are not administered. Patient and nursing attitudes and behaviors can influence whether a patient receives a dose. The objective of this single center study was to evaluate prescriber knowledge and attitudes regarding missed doses of pharmacologic VTE prophylaxis. An anonymous, 9-question survey was administered to internal medicine and general surgery resident physicians. The survey captured prescriber opinions on issues related to non-administration of VTE prophylaxis. Thirty-two percent of medicine residents compared with 3 % of surgery residents felt pharmacologic VTE prophylaxis was not necessary in an independently ambulating patient (P < 0.001). Medicine residents were more likely to agree that it is appropriate for nurses to make clinical decisions to determine whether a dose of pharmacologic VTE prophylaxis should be administered to a patient (24 vs. 0 %, P < 0.001). Study findings indicate the need for additional resident physician education. Further investigation is needed to assess these beliefs and ensure patients receive necessary VTE prophylaxis.

Is the Meaningful Use Venous Thromboembolism VTE-6 Measure Meaningful? A Retrospective Analysis of One Hospital's VTE-6 Cases.

BACKGROUND: Venous thromboembolism (VTE) is a common, often deadly cause of preventable harm for hospitalized patients. The Centers for Medicare & Medicaid Services Meaningful Use VTE-6 measure automatically captures data documented in a Meaningful Use-certified electronic health record (EHR) to identify patients with potentially preventable VTE, defined as those who developed radiologically confirmed, in-hospital VTE and did not receive prophylaxis between admission and the day prior to the diagnostic test order date. The validity of the Meaningful Use VTE-6 measure was assessed by reviewing the quality of VTE prophylaxis provided to patients identified by the measure. METHODS: A retrospective chart review was performed on all patients identified by VTE-6 during the first year of Meaningful Use Stage 1. The following information was abstracted from the Meaningful Use-certified EHR: patient demographics, clinical data, VTE prophylaxis prescribed and administered, and diagnostic testing. These data were then analyzed to assess prevention efforts prior to each VTE event and identify potential targets for improvement. RESULTS: Fifteen patients were identified as having sustained potentially preventable VTE by the Meaningful Use VTE-6 measure. Nine (60%) of the 15 patients identified were false positives and did not meet the rationale of the measure. For only 6 (40%) of the 15 patients was VTE considered to be truly potentially preventable; those patients provided targets for quality improvement measures. CONCLUSIONS: The majority of patients identified by the Meaningful Use VTE-6 algorithm did not suffer truly potentially preventable VTE. Misclassification of VTE as "potentially preventable" hinders efforts to target true opportunities for quality improvement.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

BACKGROUND: All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. OBJECTIVES: The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. RESEARCH DESIGN: This was a retrospective cohort study of a quality improvement intervention. SUBJECTS: The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. MEASURES: In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. RESULTS: Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. CONCLUSIONS: Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.