Background:

An estimated 1 million people in the US develop symptomatic venous thromboembolism (VTE) at a cost of $1.5 billion annually. The American College of Chest Physicians recommends treating deep vein thrombosis (DVT) outpatient whenever possible, and the British Thoracic Society recommends outpatient treatment for stable pulmonary embolism (PE). Background research at our institution identified significant variation in VTE care provided, often based on patient insurance status. We aimed to standardize VTE care from hospital presentation to PCP follow–up with the explicit goals of: decreasing number of hospital admissions and length of stay, providing system–wide patient & provider education, and mitigating care disparities among patients based on insurance status.

Methods:

Our target population was acute VTE patients presenting to the ED and/or admitted to medicine services. The intervention consisted of: admission & discharge order sets; provider education through e–mail reminders & comprehensive anticoagulation pocket cards; patient education including a DVD about warfarin therapy, Care Notes® handouts, and nursing instruction on self–injection of low molecular weight heparin; and 72 hour follow–up phone calls. Evaluation of the intervention was completed through prospective chart review & phone interviews at both 72 hours and six weeks following discharge. Study data (n=135) was obtained from 2/1/11 to 11/28/11 and compared to retrospective data on VTE patients at our institution (n=236) from 12/1/07 to 04/30/09.

Results:

135 patients entered the VTE Clinical Care Pathway during the study period: 53 DVT (39.3%) & 82 PE (+/–DVT) (60.7%). The study population had more women (53.3% vs. 47.2%), uninsured (34.8% vs. 28.6%), and PE patients (60.7% vs. 54.7%) compared to previous data, while percentage of VTE patients admitted (73% vs. 73%) and age (51 vs. 53) were similar. Length of stay decreased from 4.4 days to 2.5 days (p<0.001), and from 5.1 days to 2.5 days among uninsured (p=0.01). 30–day ED recidivism decreased from 16.6% to 14.8% (p=0.65), and from 24.2% to 6.4% among uninsured (p=0.35). Eight patients(6%), were readmitted for VTE–related issues during the study period, down from 8% (p=0.44). Cost per VTE admission overall decreased from $7610 to $4474 (p<0.001), and from $9953 to $3891 (p=0.002) per uninsured patient. Projected annually, total VTE costs will decrease $526,848, from $1,270,480 to $751,632.

Conclusions:

Implementing a standardized, systematic and multi–disciplinary clinical care pathway for acute VTE dramatically reduced hospital utilization and cost, particularly among uninsured patients. Through this quality improvement project and strong collaboration with local community health clinics in providing timely follow–up, this is strong evidence for improving VTE care, conserving limited resources, and potentially developing similar models of care for other disease states among uninsured patients.