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

Abstract

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.

Figure 1

compares the rates for risk-appropriate VTE prophylaxis prescription for black (hashed gray) and white (dark gray) patients before and after implementation of the mandatory computerized provider order entry (CPOE) clinical decision support (CDS) VTE module on the trauma (A) and internal medicine (B) services. The proportion of patients prescribed best-practice VTE prophylaxis increased significantly (p<0.05) within both race categories for both trauma and internal medicine patients.

Figure 2

compares the rates for risk-appropriate VTE prophylaxis prescription for female (dark gray) and male (hashed gray) hospitalized patients before and after of the mandatory CPOE clinical decision support VTE module was implemented on the trauma (A) and internal medicine (B) services. The proportion of patients prescribed best-practice VTE prophylaxis increased significantly (p<0.05) within both gender categories for both trauma and internal medicine patients.