Kristen Nordenholz, MD, MSc

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

RESULTS

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

RESULTS

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

RESULTS

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.