m189 - conference slide deck for...
TRANSCRIPT
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Keynote Speaker
Dr. William Geerts, MD, FRCPCProfessor, Department of Medicine, University of Toronto,
Director, Thromboembolism Program, Sunnybrook Health Sciences Centre, Toronto, ON
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Faculty/Presenter Disclosure
• Faculty: Dr. William Geerts• Relationships with commercial interests:*
– Grants/Research Support: NA– Speakers Bureau/Honoraria: Bayer, Leo Pharma, Sanofi– Advisory Boards: Bristol-Myers Squibb, Leo Pharma– Other: Bayer, GSK, Sanofi
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Disclosure of Commercial Support• This program has received financial support from Alexion Canada, Leo
Pharma, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Covidien, Novartis, Octapharma, BMS/Pfizer Alliance, Pfizer Canada Injectables, Aspen Pharmacare and Sanofi in the form of an Unrestricted Educational Grant
• This program has not received in-kind support from any commercial organization
• Potential for conflict(s) of interest:– Dr. William Geerts has received payment from Bayer, Leo Pharma,
Sanofi.– Bayer, Leo Pharma and Sanofi developed/licenses/distributes/benefits
from the sale of a product that will be discussed in this program:
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Mitigating Potential Bias
• No commercial or other non-commercial organization have had any input to the content of this program
• No commercial or other non-commercial organization have been present at or privy to any discussions, meetings, or other activities related to the content of this program
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Reducing Hospital-Acquired VTE: A “Nomadic” Quality
Improvement JourneyBill Geerts, MD, FRCPC
Director Thromboembolism Program, Sunnybrook HSCProfessor of Medicine, University of Toronto
Executive, Thrombosis CanadaNational Lead, VTE Prevention, Safer Healthcare Now!
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Brief, selective and personal discussion of the road to improved patient safety through the optimal use of thromboprophylaxis
Outline
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Is it a problem?
Hospital-Acquired VTE
Can it be fixed?
Can it be fixed consistently?
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Is it a problem?
Hospital-Acquired VTE
Can it be fixed?
Can it be fixed consistently?
Clinical research
Practice guidelines
QI – local, national
QI research
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Why are we concerned about thromboprophylaxis?
1. Because 60% of all venous thromboembolism (VTE) in the population is hospital-acquired
2. Because VTE causes substantial harm
3. Because HA-VTE can be prevented (effectively, safely, inexpensively)
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Consequences of Unprevented VTE
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Burden of Hospital-Acquired VTE
Population of Ontario, 201413,679,000
Annual VTE rate13,679
Hospital-acquired VTE rate8,000/year
1/1,000/yr
60%
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1. More than 450 randomized trials show that VTE can be safely prevented
2. Guidelines have recommended routine thromboprophylaxis for 28 years
3. Thromboprophylaxis is standard of care for almost all hospital patients in 2014
Evidence for Thromboprophylaxis
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What is the evidence?
Consistent 60-70% reduction in asymptomatic VTE without a significant increase in major bleeding
But, does prophylaxis improve clinically-important outcomes?
4 recent examples
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QI improves Thromboprophylaxis
54% 67% 80% 90% 98%
Maynard – J Hosp Med 2010;5:10
1
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QI efforts also reduce VTE
Maynard – J Hosp Med 2010;5:10
Risk assessment tool linked to recommended prophylaxis options Active monitoring, feedback and interventions to improve adherence
2005 2007 P
Patients at risk 9,720 11,207
Appropriate prophylaxis 58% 98% <0.001
Hospital-acquired VTE
131 92 <0.001
Preventable hospital-acquired VTE
44 7 <0.001
1
2
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Thromboprophylaxis leads to Fewer Adverse Outcomes
Zeidan – Am J Hematol 2013;88:545
2.5%
1.1%
0%
0.5%
1.0%
1.5%
2.0%
2.5%
Symptomatic VTE
Preventable VTE
Clinical Events at 90 days
Major bleeding
0.7%
0%0.3%
0.1%
Pre‐intervention (N=1,000)
Post‐intervention (N=942)
Medical patients at Johns Hopkins
2 Increased Thromboprophylaxis leads to Fewer Adverse Outcomes
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QI project at King’s College Hospital, London launched in 2010
Developed a local VTE Prevention Program Mandatory, documented VTE risk assessment VTE prophylaxis guidance Mandatory VTE education for staff Identification of hospital-associated VTE Root cause analysis with subsequent targeted
QI interventions
Effect of a VTE Prevention Program on HA-VTE
Roberts – Chest 2013;144:1276
3
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Patients with a VTE Risk Assessment
Roberts – Chest 2013;144:1276
% o
f pat
ient
s
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QI project at King’s College Hospital, London, 2010-12
VTE Prevention Program Reduces HA-VTE
Roberts – Chest 2013;144:1276
2010-11 2011-12 p
VTE risk assessment
63% (38-88) 93% (90-97)
HA-VTE
Per 1,000 admissions
23619.7/mo
1.5
18915.8/mo
1.0
0.014
Potentially preventable HA-VTE 43% 32% 0.005
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Hospital-Acquired VTE in the UK
Lester – Heart – 2013;99:1734
Readmissions with VTE 8,578 In-hospital fatal VTE 4,334 Fatal VTE disch-90 days 1,651 In-hosp/post-disch fatal VTE 5,985
4,141,000 admissions >3 days in all 163 NHS hospital
trusts, 2010-12
1. 1/500 admissions are readmitted with VTE
2. 1/700 admissions die of VTE <90 days
4
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All patients admitted to all 163 NHS trusts, 2010-12 Mandatory reporting of use of the VTE risk tool
Use of the UK National VTE Risk Assessment Tool
Lester – Heart – 2013;99:1734
Rate of VTE risk
assessments performed
[IQR]
100%
0%
50%
July 2010 March 2012
51% [27,71]
93% [91,96]
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All 4 million patients admitted to all 163 NHS hospital trusts >3 days, 2010-12
Hospital-Acquired Fatal VTE is Reduced in Adherent Hospitals
Lester – Heart – 2013;99:1734
Fatal VTE <90 days after hospital discharge
Rel Risk for hospitals with VTE risk assessment
>90% vs <90% All 0.85 [0.75-0.96; p=0.01]
Post-discharge 0.81 [0.67-0.79; p=0.03]
Achieving >90% VTE risk assessment is associated with significant lower VTE mortality
Hospital-Acquired Fatal VTE is Reduced in Adherent Hospitals
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National VTE Mortality DataEngland
Year VTE listed as cause of death
2007 6,1212008 6,1702009 6,2182010 6,2822011 4,5622012 4,668
From R. Arya - Office for National Statistics, 2013
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Better Prophylaxis Options Reduce the Risk of DVT after TJR
60%
50%
40%
30%
20%
10%
0
DVT
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2006 Routine Use of Recommended Prophylaxis in 195 Canadian Hospitals
100%
75%
50%
25%
0 86%94% 30% 32% 11%36% 33%
Appropriate use
Knowledge-care gap
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Prophylaxis use in 8 Toronto hospitals
100%
80%
60%
40%
20%
0Hip Major general Medical Combined
fracture surgery patients (n=341) (n=416) (n=418) (n=1,175)
79%
43%
31%
49%
Knowledge-care gap
Appropriate use
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Oral Rivaroxaban after THR/TKR
Turpie – Thromb Haemost 2011;105:444
%
10
8
6
4
2
0
9.4%
4.2%
Risk reduction
55% p<0.001
0.3% 0.4 %
All VTE Symptomatic Major VTE bleeding
enoxaparin(n=6,200)
rivaroxaban(n=6,183)
P=0.141.0% 0.5%
Risk reduction
50% p=0.001
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Advantages of rivaroxaban Thromboprophylaxis in TJR
More effective and as safe as LMWH
Oral, once daily
No lab monitoring
Cheaper than LMWH (~$3/day in Canada; in Ontario, covered by ODB for TJR)
Post-discharge prophylaxis is simple and inexpensive high compliance
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0 1 2 3 4 5 6 7 8 9 10 14 21 28days
rivaroxaban 10 mg PO once daily low molecular weight heparin SC
Admit
ORDischargeor rehab
Prophylaxis in Hip and Knee Arthroplasty start postop
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2014 Thromboprophylaxis Summary
Patient Group Options DurationAcute medical illness
LMWH Discharge
Surgery: general, gyne, thorac, urol
LMWH Discharge (up to 4 wks for selected cancer patients)
Major orthopedics - THR, TKR
- Hip fracture surg
rivaroxaban LMWH
LMWH
2-6 weeks
2-6 weeks
High bleeding risk mechanical Until LMWH can start
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Prophylaxis Use in Medical Patients 1,894 consecutive patients in 29 hospitals in 6 provinces
Khan – Thromb Res 2007;119:145
90%Prophylaxis Prophylaxis
Recommendedindicated given
prophylaxis
23% 15%
100%
75%
50%
25%
0
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Looks like ol’ Bill’s tryin’ uh git dem
surgeons to use duh prophylaxis guidelines
agin.
Yah Pa, poor fool. But ah heared the cavalry’s
comin’!
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ACCREDITATION CANADA VTE Prophylaxis Required
Organizational Practice (ROP)
Hospital accreditation requirement started January, 2011
www.accreditation.ca
The hospital “identifies medical and surgical clients at risk of venous thromboembolism (DVT and PE) and provides appropriate thromboprophylaxis.”
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ACCREDITATION CANADA VTE Prophylaxis ROP
1. The hospital has an organization-wide, written thromboprophylaxis policy or guideline.
2. Identifies patients at risk for VTE and provides appropriate, evidence-based VTE prophylaxis.
3. Establishes measures for appropriate thromboprophylaxis use, audits its implementation, and uses this for quality improvement.
4. Identifies major orthopedic surgery patients who require post-discharge prophylaxis and provides it.
5. Educates health professionals and patients about VTE and its prevention.
www.accreditation.ca
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April 10 to 18, 2013
118 centers, 4,667 patients, 9 provinces coast to coast
General medical and general surgical patients at risk for VTE
Analyses conducted by Central Measurement Team on data from Patient Safety Metrics (PS Metrics)
2013 VTE Audit Day2013 National VTE Audit
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Overall, appropriate thromboprophylaxis use = 81%
- Very good (but with room for improvement)
Thromboprophylaxis Use 2013 National VTE Audit
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Appropriate Thromboprophylaxis -by Province (2013)
% o
f pat
ient
s
100%
65%
Appropriate Thromboprophylaxis by Province (2013)
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Receiving Appropriate Thromboprophylaxis and Preprinted Order Sets
N=4,518
Order set used
Order set not used
91%
71%
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9%
2003 2007 2008 2009 2010 2011 2012 2013 2014
21%
100%
75%
50%
25%
0
60%
94%72%
79%
Appropriate Prophylaxis* Use in General IM Patients
91%
Baseline Education, commitment Order sets, audit & feedback
90% 87%
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Improving Thromboprophylaxis
1. Institutional commitment + resource support2. PLUS multidisciplinary team, committee or sub-3. PLUS input from similar organizations (Baycrest,
Providence, etc)4. PLUS develop written hospital policy5. PLUS embed into order sets6. PLUS audit adherence with 4.7. PLUS QI initiative – education, re-audit +
feedback8. PLUS periodically re-assess approach
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It’s all about the patient . . .At your hospital, do 100% of
patients considered to be at risk for VTE receive appropriate
prophylaxis 100% of the time?Yes No
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Take Home Messages National/provincial incentives are important to
achieve widespread impact Local practice change (= a culture change)
requires multi-faceted approaches and a lot of patience
QI almost always takes longer than you think VTE prophylaxis is a real success story in
Canada
Measure
Make changes
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“Bill, for goodness sake, stop asking if we’re there yet. We’re nomads*, we’ll never be there.”
*quality improvement workers
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Congratulations, to all of you for making thromboprophylaxis such
a success story in Canada