Venous thromboembolism (VTE), which comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE), is the most common preventable cause of hospital death. Veterans with cancer, and particularly those who undergo surgery are at particularly high risk with up to one-third of untreated patients (no prophylaxis) developing deep venous thrombosis. Guidelines from the American College of Chest Physicians recommend prophylaxis throughout the hospital course and continuing post discharge for 4 weeks after surgery. Current hospital process measures (VA Surgical Quality Improvement Program-VASQIP VTE measure, Joint Commission's Surgical Care Improvement Project SCIP-VTE-2) only examine prophylaxis during the procedure or in the 24 hours around the time of surgery rendering them inadequate in evaluating and promoting performance. Collaborative training modules from the Illinois Surgical Quality Improvement Collaborative (ISQIC) are available to raise awareness of VTE risk and prevention strategies among surgeons, surgical care teams, nurses and patients. We propose a VISN 12 directed evaluation to determine the effect of VTE risk education modules on both inpatient and outpatient VTE prophylaxis. We propose the following Specific Aims:
Aim1 : To determine whether multi-modal, provider-focused educational interventions can improve receipt of VTE inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis after major cancer surgery in four VISN 12 hospitals. H1: Scalable interventions for postoperative VTE prophylaxis can be effective in addressing local care barriers to receipt of inpatient chemoprophylaxis and ordering of post-discharge chemoprophylaxis. The interventions will include the ISQIC VTE Bundle elements: Caprini risk assessment tools, audit/feedback of provider prescribing habits, risk awareness education for nurses and patients.
Aim 2 : To identify patient and nursing provider perceptions of barriers to guideline-concordant care during the transition from inpatient to outpatient postsurgical VTE prophylaxis. H1: Inpatient and post-discharge prophylaxis adherence is variable for Veterans after major cancer surgery due to lack of VTE risk awareness.
Aim 3 : To perform a cost identification and budget impact analysis of increasing adherence to VTE prophylaxis guidelines. H1: The cost of increased delivery of VTE chemoprophylaxis will be offset by decreased cost of VTE treatment.
These aims will evaluate the implementation of ISQIC training bundles, leveraging the integrated VHA healthcare delivery system and existing databases to improve surgical outcomes. These interventions build on prior work identifying gaps in guideline-concordant, post-surgical care and on preliminary testing outside the VA in the Illinois Surgical Collaborative. This study is innovative in that both quantitative and qualitative methods will evaluate how providers adopt post-surgical risk education. This study will also provide new knowledge on the value of a surgical quality improvement collaborative (QIC) for VTE prophylaxis, as well as nursing and patient perceptions on risk of VTE after major cancer surgery.

Public Health Relevance

DVT and pulmonary embolism affect nearly 1 million Americans each year, resulting in about 300,000 deaths. Certain surgical procedures such as orthopedic and neurosurgical procedures are well known to be associated with higher risk of venous thromboembolism (VTE). Cancer is also a known risk factor for VTE and major cancer operations carry significant risk of VTE during the entire four week postoperative period. VTE prophylaxis is recommended throughout the hospital stay after cancer surgery and after hospital discharge; however, studies have demonstrated variable adherence with this recommendation in part due to little information on the most effective and cost effective treatment. Collaborative training modules are available to raise awareness of VTE risk and prevention strategies among surgeons, surgical care teams, nurses and patients. We propose a directed evaluation at VISN 12 Illinois hospitals to determine the effect of a VTE risk education module on both inpatient and outpatient VHA VTE prophylaxis.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Health Care and Clinical Management (HS1A)
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Jesse Brown VA Medical Center
United States
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