Purpose: Computer-based tools to assess venous thromboembolism (VTE) risk have been shown to increase VTE pharmacoprophylaxis rates and decrease VTE incidence in hospitalized patients. However, these tools are dependent on the quality of electronically available clinical data; if the clinical data needed for accurate VTE risk assessment is incomplete, VTE risk may be underestimated in at-risk patients. We hypothesized that a physician-enhanced clinical decision support (CDS) tool would identify more patients as moderate and high-risk than computer-based tools alone that do not incorporate physician input.
Method: Our institution implemented a physician-enhanced CDS tool that required physicians to stratify hospitalized patients as high, moderate, or low-risk for VTE based on assessment of VTE risk factors enhanced with individual physician judgment. We compared rates of VTE pharmacoprophylaxis and VTE incidence in adult patients hospitalized 4 months prior and 3 months after implementation of the physician-enhanced CDS tool. The study sample was restricted to adult hospitalized patients who were determined to be at low-risk for VTE, and would not have received pharmacoprophylaxis based on a computer-based tool alone.
Result: During the 7-month study period, 25.4% (n=2423) of hospitalized adult patients would have been deemed low-risk for VTE based on a computer-based risk assessment tool alone. After implementation of the physician-enhanced CDS tool, physicians stratified 324 (27.1%) of these patients as moderate-risk and 99 (8.3%) as high-risk for VTE. After implementation of the physician-enhanced CDS tool, the rate of VTE pharmacoprophylaxis in this sample increased (27.1% to 35.1%, p<0.01) and the incidence of in hospital VTEs decreased (0.98% to 0.25%, p=0.02).
Conclusion: Patients identified as low- risk for VTE solely by computer-based algorithms may miss patients that physicians determine to be at risk for VTE and warrant VTE prophylaxis. Physician-enhanced clinical decision support tools that involve clinician-guided risk assessment may outperform computer-based VTE risk stratification algorithms. However, adverse events that might occur as a result of expanded VTE pharmacoprophylaxis from CDS tools need to be determined.