Inaccuracy of Initial Clinical Mobility Assessment in Venous Thromboembolism Risk Stratification.

BACKGROUND: Venous thromboembolism risk increases in hospitals due to reduced patient mobility. However, initial mobility evaluations for thromboembolism risk are often subjective and lack standardization, potentially leading to inaccurate risk assessments and insufficient prevention. METHODS: A retrospective study at a quaternary academic hospital analyzed patients using the Padua risk tool, which includes a mobility question, and the Johns Hopkins-Highest Level of Mobility (JH-HLM) scores to objectively measure mobility. Reduced mobility was defined as JH-HLM scores ≤3 over ≥3 consecutive days. The study evaluated the association between reduced mobility and hospital-acquired venous thromboembolism using multivariable logistic regression, comparing admitting health care professional assessments with JH-HLM scores. Symptomatic, hospital-acquired thromboembolisms were diagnosed radiographically by treating providers. RESULTS: Of 1715 patients, 33 (1.9%) developed venous thromboembolism. Reduced mobility, as determined by the JH-HLM scores, showed a significant association with thromboembolic events (adjusted OR: 2.53, 95%CI:1.23-5.22, P = .012). In contrast, the initial Padua assessment of expected reduced mobility at admission did not. The JH-HLM identified 19.1% of patients as having reduced mobility versus 6.5% by admitting health care professionals, suggesting 37 high-risk patients were misclassified as low risk and were not prescribed thrombosis prophylaxis; 4 patients developed thromboembolic events. JH-HLM detected reduced mobility in 36% of thromboembolic cases, compared to 9% by admitting health care professionals. CONCLUSION: Initial mobility evaluations by admitting health care professionals during venous thromboembolism risk assessment may not reflect patient mobility over their hospital stay. This highlights the need for objective measures like JH-HLM in risk assessments to improve accuracy and potentially reduce thromboembolism incidents.

Silent cerebral infarction during immune TTP remission: prevalence, predictors, and impact on cognition.

Immune thrombotic thrombocytopenic purpura (iTTP) survivors have increased risk of cardiovascular disease, including strokes, and report persistent cognitive difficulties during remission. We conducted this prospective study involving iTTP survivors during clinical remission to determine the prevalence of silent cerebral infarction (SCI), defined as magnetic resonance imaging (MRI) evidence of brain infarction without corresponding overt neurodeficits. We also tested the hypothesis that SCI is associated with cognitive impairment, assessed using the National Institutes of Health ToolBox Cognition Battery. For cognitive assessments, we used fully corrected T scores adjusted for age, sex, race, and education. Based on the diagnostic and statistical manual 5 criteria, we defined mild and major cognitive impairment as T scores with a 1 or 2 standard deviation (SD) and >2 SD below the mean on at least 1 test, respectively. Forty-two patients were enrolled, with 36 completing MRIs. SCI was present in 50% of the patients (18), of which 8 (44.4%) had prior overt stroke including during acute iTTP. Patients with SCI had higher rates of cognitive impairment (66.7% vs 27.7%; P = .026), including major cognitive impairment (50% vs 5.6%; P = .010). In separate logistic regression models, SCI was associated with any (mild or major) cognitive impairment (odds ratio [OR] 10.5 [95% confidence interval (95% CI), 1.45-76.63]; P = .020) and major cognitive impairment (OR 7.98 [95% CI, 1.11-57.27]; P = .039) after adjusting for history of stroke and Beck depression inventory scores. MRI evidence of brain infarction is common in iTTP survivors; the strong association of SCI with impaired cognition suggests that these silent infarcts are neither silent nor innocuous.

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

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.

Systematic Undercoding of Diagnostic Procedures in National Inpatient Sample (NIS): A Threat to Validity Due to Surveillance Bias.

BACKGROUND AND OBJECTIVES: Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives. METHOD: We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE. RESULTS: In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE. CONCLUSIONS: Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.

Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis.

OBJECTIVE: To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN: Prospective cohort study. SETTING: The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS: All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION: Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS: During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE: Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.

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.

Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review.

BACKGROUND: Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital. METHODS: We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality. RESULTS: Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen. INTERPRETATION: We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.

Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race?

BACKGROUND: Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. METHODS: A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. RESULTS: Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46-0.81, p<0.001), white (OR 0.57; 95% CI, 0.44-0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29-0.88, p = 0.015). CONCLUSION: Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient's understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

Defects in Processes of Care for Pharmacologic Prophylaxis Are Common Among Neurosurgery Patients Who Develop In-Hospital Postoperative Venous Thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) is a cause of considerable morbidity and mortality in hospitalized patients. An evidence-based algorithm was developed and implemented at our institution to guide perioperative VTE prophylaxis management. OBJECTIVE: We evaluated compliance with prescription of risk-appropriate VTE prophylaxis and administration of prescribed VTE prophylaxis in neurosurgery patients. METHODS: This was a retrospective analysis of postoperative neurosurgery patients at a single institution with subsequent diagnosis of acute VTE during their inpatient stay. Descriptive statistics were used to characterize pharmacologic VTE prophylaxis and prescribing patterns. RESULTS: The incidence of VTE in our neurosurgery population was 248/13,913 (1.8%). Of the 123 patients, the median time to VTE diagnosis was 96 hours after surgery (interquartile range [IQR], 58-188 hours). A total of 108 patients (87.8%) were prescribed risk-appropriate VTE prophylaxis, among whom 61 (56.5%) received all doses as prescribed. Fifty-three patients (43.1%) missed ≥1 dose of prescribed prophylaxis and the median missed doses was 3 (IQR, 0-3). The median time to first dose of pharmacologic VTE prophylaxis was 42 hours (IQR, 28-51). More than half (n = 63, 51.2%) of the VTE risk assessments contained ≥1 error, of which 15 (23.8%) would have resulted in a change in recommendation. CONCLUSIONS: Our evidence-based VTE prophylaxis algorithm was not accurately completed in more than half of patients. Many patients who developed VTE had a defect in their VTE prophylaxis management during their inpatient stay. Research to improve optimal VTE prevention practice in neurosurgery patients is needed.

Synthetic cannabinoid-associated coagulopathy secondary to long-acting anticoagulant rodenticides: Observational case series and management recommendations.

Synthetic cannabinoids have become increasingly popular drugs of abuse due to low cost and inability to detect these substances on routine drug screenings. In the United States, incidence of synthetic cannabinoid contamination with long-acting anticoagulant rodenticides (LAARs) resulting in coagulopathy and bleeding complications has been described.We sought to describe the natural history, management approach, and outcomes of bleeding secondary to synthetic cannabinoid-associated LAAR toxicity in an observational case series of patients evaluated at an urban academic medical system.We conducted an observational study of patients with suspected exposure to LAAR-contaminated synthetic cannabinoids and associated bleeding treated within the Johns Hopkins Health System.In this 16 subject cohort, hematuria was the most common bleeding symptom at presentation. The majority of the cohort (75%) had international normalized ratio (INR) > 9.6 at presentation. Of the 13 patients with brodifacoum testing, 12/13 (92%) were positive. Twelve patients (75%) had at least 1 INR value below 2 within 24 hours of the first INR measurement. Of this cohort, 1/16 (6%) died in hospital. The median length of hospital stay was 4 days, (interquartile range = 3-6). The average cost of pharmacological treatment for coagulopathy during inpatient hospitalization was $5300 (range, $2241-$8086).In patients presenting with unexplained coagulopathy it is important for emergency department providers to consider LAAR intoxication and consider formal testing for brodifacoum to assist with treatment planning. Use of a standardized management algorithm including intravenous/oral vitamin K, judicious use of blood products and close laboratory monitoring is essential to optimizing outcomes.

Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis.

PURPOSE: This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS: This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS: From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and ≥ 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. CONCLUSIONS: Though only one-third of patients ≥100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients.

Implementation of patient education software in an anticoagulation clinic to decrease visit times for new patient appointments.

OBJECTIVE: Patient education on high-risk medications such as warfarin is important, and they require quick follow-up after initiation to maximize efficacy and safety. In our Anticoagulation Clinic, two 60-minute new patient appointments are available each day, contributing to prolonged lead-time. We instituted standardized warfarin video education to shorten in-clinic-room visit time, to potentially increase new patient appointments. METHODS: Patients viewed the video in the waiting area with a goal to decrease visit times by 15 min (25%), before pharmacists completed their visit. Data collected included time spent in the clinic room, education comprehension, and patient feedback. RESULTS: Ninety patient visits were evaluated in one pre-intervention and two post-intervention phases. Patients who received video education spent less time in the clinic room versus those who had not (52.4 vs 39.4 min, p = 0.001), and two-thirds of all post-intervention visits achieved 25% reduction in visit time. There were no significant differences in education comprehension and patient satisfaction. CONCLUSION: Video education significantly decreased in-clinic-room visit time, and most patients achieved a goal of 25% reduction in time spent, without a change in comprehension or patient satisfaction. PRACTICE IMPLICATIONS: Implementation of video education can reduce clinic times in many patients without significantly impacting patient satisfaction.

Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients.

PURPOSE: Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. METHODS: The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. RESULTS: Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. CONCLUSION: Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.

Venous Thromboembolism in Patients Hospitalized for Lung Transplantation.

BACKGROUND: Venous thromboembolism (VTE) is an important complication after solid organ transplantation. We sought to evaluate any association between VTE and in-hospital death, length of hospitalization, and total hospital charges for patients hospitalized for lung transplantation (LT). METHODS: We retrospectively reviewed the Nationwide Inpatient Sample to identify patients hospitalized for LT from 2000 to 2011. We evaluated the incidence of VTE during hospitalization for LT, risk factors for VTE, and the association between VTE and in-hospital death, length of hospitalization, and total hospital charges. RESULTS: Of the 16,318 adults hospitalized for LT during the study period, VTE developed in 1,029 (6.3%), including 854 (5.4%) with deep vein thrombosis alone and 175 (1.1%) with pulmonary embolism. The factors associated with VTE included age older than 60 years (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.03 to 1.94), female sex (OR, 0.61; 95% CI, 0.44 to 0.86), and receiving mechanical ventilation support for 96 hours or more (OR, 3.38; 95% CI, 2.49 to 4.58). The adjusted odds of in-hospital death in patients with pulmonary embolism was thrice as high as those without any VTE (OR, 3.40; 95% CI, 1.29 to 8.99). Among LT patients with VTE, the average length of hospitalization was 38% (95% CI, 27% to 48%) longer, and the total cost of hospitalization was 23% (95% CI, 16% to 30%) higher compared with LT patients without VTE. CONCLUSIONS: VTE is a relatively frequent complication among LT recipients and is associated with increased death, total hospital length of stay, and hospital charges. These data indicate that prophylaxis practices should be reexamined to reduce this preventable complication.