Impact of Clinical Decision Support with Mandatory versus Voluntary Venous Thromboembolism Risk Assessment in Hospitalized Patients.

Background Venous thromboembolism (VTE) causes significant preventable morbidity and mortality in hospitalized patients. Assessing VTE risk is essential to initiating appropriate prophylaxis and reducing VTE outcomes. Studies show that computerized clinical decision support (CDS) can improve VTE risk assessment (RA), prophylaxis, and outcomes but few examined the effectiveness of specific design features. From 2008 to 2016, University of Michigan Health implemented CDS for VTE prevention in four stages, which alternated between voluntary and mandatory RA using the 2005 Caprini model and generated inpatient orders for risk-appropriate prophylaxis based on CHEST guidelines. This cross-sectional study evaluated the impact of mandatory versus voluntary RA on VTE prophylaxis and outcomes for adult medical and surgical patients admitted to the health system. Methods Interrupted time series analysis was conducted to evaluate the trend in smart order set-recommended VTE prophylaxis by CDS stage. Logistic regression with CDS stage as the primary independent variable was used in pairwise comparisons of VTE during hospitalization and within 90 days post-discharge for mandatory versus voluntary RA. Adjusted odd ratios (ORs) were calculated for total, in-hospital, and post-discharge VTE. Results In this study of 223,405 inpatients over 8 years, smart order set-recommended prophylaxis increased from 65 to 79%; it increased significantly when voluntary RA in Stage 1 became mandatory in Stage 2 (10.59%, p < 0.001) and decreased significantly when it returned to voluntary in Stage 3 (-11.24%, p < 0.001). The rate increased slightly when mandatory RA was reestablished in Stage 4 (0.23%, p = 0.935). Adjusted ORs for VTE were lower for mandatory RA versus adjacent stages with voluntary RA. The adjusted OR for Stage 2 versus Stage 1 was 14% lower ( p < 0.05) and versus Stage 3 was 11% lower ( p < 0.05). The adjusted OR for Stage 4 versus Stage 3 was 4% lower ( p = 0.60). These results were driven by changes in in-hospital VTE. By contrast, the incidence of post-discharge VTE increased in each successive stage. Conclusion Mandatory RA was more effective in improving smart order set-recommended prophylaxis and VTE outcomes, particularly in-hospital VTE. Post-discharge VTE increased despite high adherence to risk-appropriate prophylaxis, indicating that guidelines for extended, post-discharge prophylaxis are needed to further reduce VTE for hospitalized patients.

Physician Assistant and Nurse Practitioner Utilization in Academic Medical Centers.

The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.

Building a Team-Based Gastroenterology Practice With Advanced Practice Providers.

The use of advanced practice providers (APPs), such as nurse practitioners and physician assistants, has grown substantially in gastroenterology practices in the United States. The first formal training programs appeared in the mid-1960s; however, incorporation of APPs into gastroenterology practices occurred sporadically until the early 1990s, when several large practices began utilizing APPs in both outpatient and inpatient environments. Over the next 20 years, APPs became increasingly more common. In hospital settings, they provide continuity of care, especially for practices that rotate physicians into hospital services on a periodic basis. Efficient use of APPs frees physicians to focus on new patients, procedures, and complex chronic care management. APPs who have independent, appropriately managed schedules can generate revenue that covers salary and benefits. Billing and coding for APPs can be complex, but once regulatory issues are understood, these aspects become straightforward and can be easily applied to gastroenterology practices. There is an ongoing need for more formal training and onboarding resources, which could be met by national gastroenterology and hepatology societies. This article reviews the various ways in which APPs can be incorporated into gastroenterology and hepatology care.

A prospective evaluation of standard versus battery-powered sequential compression devices in postsurgical patients.

BACKGROUND: Sequential compression devices (SCDs) reduce deep venous thrombosis in postsurgical patients, but the use is hindered by poor compliance. METHODS: General and orthopedic surgery patients (n = 67) were randomized to standard- or battery-powered SCDs. Compliance was documented hourly. Nurses and patients were issued a survey to assess barriers to compliance and device satisfaction. RESULTS: Compliance with standard SCDs was 47% compared with 85% with battery-powered SCDs (P < .001). The most common barriers identified by nurses and patients were ambulation and transfers, which were mitigated with the battery-powered device. A majority (79%) of those issued a battery-powered device reported no major problems compared with only 14% of patients issued a standard device (P < .005). CONCLUSIONS: The dual venous thromboembolism prevention strategies of early mobilization and SCD utilization can be met with the appropriate equipment.

Productivity assessment of physician assistants and nurse practitioners in oncology in an academic medical center.

PURPOSE: Demand for oncologists will increase dramatically over the next 15 years. Physician assistants (PAs) and Nurse practitioners (NPs) have been identified as one solution to meet the projected shortages in oncology. It has previously been reported that 56% of oncologists work with PAs and NPs, more than two thirds of whom believe it benefits their practice with some noted productivity advantages. The purpose of this study was to quantify the productivity of PAs and NPs working in oncology in an academic medical center. METHODS: A 2-week self-reported time study was performed in a single large academic medical center. Services were categorized as billable, bundled, care facilitation, administrative, and other based on time spent performing services in each category. Current procedural terminology codes were used to determine the economic value of services provided. RESULTS: A total of 54 PAs and NPs were included in the final analysis. PAs and NPs reported similar clinical activities. Overall, there was high variability noted in terms of productivity, notably with PA/NP direct billable revenue. Opportunities were identified to improve utilization of oncology PAs and NPs, with suggestions for future research related to PA and NP productivity tracking. CONCLUSION: Productivity measurement for PAs and NPs can be challenging. To our knowledge, this is the first study that quantifies PA and NP productivity in oncology according to known economic indicators such as charges and work relative value units.

Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery.

OBJECTIVE: To identify independent predictors of 30-day venous thromboembolism (VTE) events requiring treatment after outpatient surgery. BACKGROUND: An increasing proportion of surgical procedures are performed in the outpatient setting. The incidence of VTE requiring treatment after outpatient surgery is unknown. METHODS: Prospective observational cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2009. Adult patients who had outpatient surgery or surgery with subsequent 23-hour observation were included. The main outcome measure was 30-day VTE requiring treatment. Patients were randomly assigned to derivation (N = 173,501) or validation (N = 85,730) cohorts. Logistic regression examined independent risk factors for 30-day VTE. A weighted risk index was created and applied to the validation cohort. Stratified analyses examined 30-day VTE by risk level. RESULTS: Thirty-day incidence of VTE for the overall cohort was 0.15%. Independent risk factors included current pregnancy (adjusted odds ratio [OR] = 7.80, P = 0.044), active cancer (OR = 3.66, P = 0.005), age 41 to 59 years (OR = 1.72, P = 0.008), age 60 years or more (OR = 2.48, P < 0.001), body mass index 40 kg/m or higher (OR = 1.81, P = 0.015), operative time 120 minutes or more (OR = 1.69, P = 0.027), arthroscopic surgery (OR = 5.16, P < 0.001), saphenofemoral junction surgery (OR = 13.20, P < 0.001), and venous surgery not involving the great saphenous vein (OR = 15.61, P < 0.001). The weighted risk index identified a 20-fold variation in 30-day VTE between low (0.06%) and highest risk (1.18%) patients. CONCLUSIONS: Thirty-day VTE risk after outpatient surgery can be quantified using a weighted risk index. The risk index identifies a high-risk subgroup of patients with 30-day VTE rates of 1.18%.

Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center.

PURPOSE: To assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization. METHODS AND MATERIALS: A workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow. RESULTS: Nearly half (46%) of physician extender time was spent performing indirect patient care. Physician extenders performed most (84.3%) of the first encounters for follow-up appointments; however, these patients were seen independently by physician assistants (PAs) and nurse practitioners (NPs) only 51% of the time. Physician extenders perceived their utilization within the department would be improved with well-defined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%). CONCLUSIONS: This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization.

Nurse practitioners and physician assistants employed by general and subspecialty pediatricians.

OBJECTIVE: There is little nationally representative information describing the current manner in which nurse practitioners (NPs) and physician assistants (PAs) work in pediatric practices and their professional activities. To understand better the current NP and PA workforce in pediatric primary and subspecialty care, we conducted a national survey of pediatricians. METHODS: A survey study of a random national sample of 498 pediatric generalists and 1696 subspecialists in the United States was performed by using a structured questionnaire administered by mail. The survey focused on practice settings, employment, and scope of work of NPs and PAs. RESULTS: Response rates were 72% for generalists and 77% for subspecialists. More than one-half (55%) of generalists reported that they do not currently work with NPs or PAs, compared with only one-third of subspecialists who do not. Many generalists and subspecialists intend to increase the number of NPs and PAs in their practices in the next 5 years. More generalist and subspecialty practices work with NPs than with PAs. There was great variability between generalists and subspecialists and among different subspecialties in the proportions that worked with NPs and PAs. The scope of work of NPs and PAs also varied between generalists and subspecialists. CONCLUSIONS: Planned increases in the number of NPs hired and expansion of their scope of work might put subspecialists and general pediatricians in competition with regard to recruitment and hiring of a limited pool of new pediatric NPs. Similar issues might arise with PAs.

Private practice rates among pediatric subspecialists.

OBJECTIVE: Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. However, increases in the absolute numbers of pediatric subspecialists in past decades, combined with greater concentrations of children in urban and suburban settings, might result in more opportunities for pediatric subspecialists to enter private practice. Our goal was to assess the proportions of subspecialists in private practice. METHODS: We surveyed a stratified, random, national sample of 1696 subspecialists from 5 subspecialties and assessed the ownership of their current clinical practice settings. RESULTS: The response rate was 77%. Two-thirds of respondents (65% [n = 705]) reported that they work in academic hospitals or outpatient clinics. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they work in community hospitals. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they work in private outpatient practices. CONCLUSIONS: There were significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Ensuring children's access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.

The effect of increased hip flexion using stirrups on lower-extremity venous flow: a prospective observational study.

BACKGROUND: Patient positioning during surgeries for colorectal cancer may represent an unrecognized risk factor for deep venous thrombosis. METHODS: Twelve healthy control patients were positioned supine with knee flexion at 90°. Duplex ultrasound examined common femoral vein (CFV) and proximal femoral vein diameter, peak systolic velocity, and volume flow with hip flexion at 0°, 30°, 60°, and 90°. Data were analyzed using the paired t test. RESULTS: In the CFV, hip flexion to 90° was associated with a significant increase in mean volume flow when compared with hip flexion at 0° (.59 vs .36 L/min; P = .05) and 30° (.59 vs .35 L/min; P = .038). In both the CFV and proximal femoral vein, increased hip flexion was associated with significantly reduced vessel diameter and increased peak systolic velocity. CONCLUSIONS: Intraoperative positioning of the lower extremities represents a modifiable risk factor for deep venous thrombosis. When stirrups are used, hip flexion of 90° maximizes venous drainage from the legs.

Physician assistant and nurse practitioner utilization in academic medical centers.

The purpose of this study was to collect information on the utilization of physician assistants (PAs) and nurse practitioners (NPs) in academic health centers. Data were gathered from a national sample of University HealthSystem Consortium member academic medical centers (AMCs). PAs and NPs have been integrated into most services of respondent AMCs, where they are positively rated for the value they bring to these organizations. The primary reason cited by most AMCs for employing PAs and NPs was Accreditation Council for Graduate Medical Education resident duty hour restrictions (26.9%). Secondary reasons for employing PAs and NPs include increasing patient throughput (88%), increasing patient access (77%), improving patient safety/quality (77%), reducing length of stay (73%), and improving continuity of care (73%). However, 69% of AMCs report they have not successfully documented the financial impact of PA/NP practice or outcomes associated with individual PA or NP care.

Pediatric physician assistants: distribution and scope of practice.

BACKGROUND: Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited. OBJECTIVE: To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice. METHODS: Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties. RESULTS: Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings. CONCLUSIONS: PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.

PA-driven VTE risk assessment improves compliance with recommended prophylaxis.

OBJECTIVE: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients, particularly surgical patients. We hypothesize that PAs are well-positioned to assist health systems with implementation of efforts to reduce the rates of this in-hospital complication and increase adherence to published standards for VTE prophylaxis. METHODS: We conducted a retrospective cohort study of general surgical patients who underwent an operation at the University of Michigan between July 2005 and June 2007. The PAs in the Department of Surgery implemented a VTE assessment and prophylaxis intervention in June 2006. Preintervention VTE risk scores were calculated using patient demographic information, operating room data, and diagnosis codes from the International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Those calculated scores were then tested on patients who had a VTE risk score documented by PAs. Postintervention VTE was determined using ICD-9-CM diagnosis codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) and identified as "acquired in hospital" or readmitted with a principal diagnosis of DVT or PE within 30 days following surgery. We then compared the frequency with which patients in the preintervention and postintervention periods received recommended VTE prophylaxis. RESULTS: Overall, 2,046 patients underwent surgery during the study period. There were 1,079 patients in the preintervention group and 967 patients in the postintervention group, with no systematic differences in the case mix between the two groups. For all patients with a risk score of 3 or higher (indicating high and highest risk combined), orders for appropriate prophylaxis improved from an average of 23.1% in the preintervention group to an average of 63.7% in the postintervention group. Similarly, for all patients with a risk score of 5 or higher (indicating highest risk), orders for appropriate prophylaxis improved from an average of 29.4% in the preintervention group to an average of 69.5% in the postintervention group. CONCLUSIONS: Through a PA-driven VTE risk assessment process, we dramatically increased the number of patients within our health system who were prescribed appropriate orders for VTE prophylaxis according to published guidelines and according to individual patient risk.