Appropriateness of Pharmacologic Thromboprophylaxis Prescribing Based on Padua Score Among Inpatient Veterans
Background: Hospitalized patients are at increased risk of developing venous thromboembolism (VTE). The Padua Prediction Score (PPS) was developed to help quantify the risk of VTE for hospitalized patients and guide prescribing of pharmacologic thromboprophylaxis. This study aims to assess whether PPS embedded within an admission order set was utilized appropriately to prescribe or withhold pharmacologic thromboprophylaxis.
Methods: This single center, retrospective observational cohort study evaluated adult patients aged ≥ 18 years between June 2017 and June 2020. A random sample of 250 patient charts meeting inclusion criteria were reviewed to calculate PPSs, and clinician notes were reviewed for documentation as to whether thromboprophylaxis was given or withheld appropriately based on the PPS. A second cohort of patients admitted within the study period meeting inclusion criteria and readmitted for VTE within 45 days of discharge were evaluated to determine appropriateness of inpatient VTE thromboprophylaxis during index hospitalization based on the PPS.
Results: Of the 250 patients examined, 118 (47.2%) had a PPS < 4 on admission. Of the 118 patients, 58 (49.2%) were inappropriately prescribed pharmacologic thromboprophylaxis administered within 24 hours of admission. The clinical rationale for giving thromboprophylaxis when not indicated was provided for only 2 (3.4%) of the 58 patients. Of the 132 patients with a PPS ≥ 4, 11 (8.3%) had thromboprophylaxis appropriately withheld and for 33 (25.0%) it was inappropriately withheld. A total of 88 (66.7%) patients received thromboprophylaxis as indicated by a PPS ≥ 4.
Conclusions: Despite the inclusion of the PPS calculator in the facility’s admission order set, this study showed pharmacologic thromboprophylaxis was frequently inappropriately given or withheld. This suggests written protocols and order sets may not be solely sufficient to ensure appropriate VTE prophylaxis in actual practice. Incorporation of additional tools, such as dashboards and scorecards, should be explored.
Limitations
There were some inherent limitations to this study with its retrospective nature and small sample size. Data extraction was limited to health records within the VA, so there is a chance relevant history could be missed via incomplete documentation. Thus, our results could be an underestimation of postdischarge VTE prevalence if patients sought medical attention outside of the VA. Given this study was a retrospective chart review, data collection was limited to what was explicitly documented in the chart. Rationale for giving thromboprophylaxis when not indicated or holding when indicated may have been underestimated if clinicians did not document thoroughly in the electronic health record. Last, for the secondary endpoint reviewing the IMPROVEDD score, a D-dimer was not consistently obtained on admission, which could lead to underestimation of risk.
Conclusions
The results of this study showed that more than one-third of patients admitted to our facility within the prespecified timeframe had pharmacologic thromboprophylaxis inappropriately given or withheld according to a PPS manually calculated on admission. The PPS calculator currently embedded within our admission order set is not being utilized appropriately or consistently in clinical practice. Additionally, results from the secondary endpoint looking at IMPROVEDD scores highlight an unmet need for thromboprophylaxis at discharge. Pathways are needed to implement postdischarge thromboprophylaxis when appropriate for patients at highest thromboembolic risk.
