From the 2024 HVPA National Conference
Ishara Lareef M.D. (Temple University Hospital), Brianna Graham M.D., Peter Rakita M.D., Shums Lareef B.A., Dharmini Shah Pandya M.D.
Background
Patients with thrombophilia are at increased risk for thrombus formation and life-threatening complications. Overutilization of inpatient thrombophilia workups, however, leads to unnecessary healthcare costs, increased burden on the healthcare system, and confusion to the patient when the results are nonspecific. Implementing a high-value care approach to unnecessary thrombophilia workups aims to ensure testing is appropriate, evidence-based, and cost-effective. This involves consideration of clinical indications for testing, understanding of pre-test probability, and utilization of guidelines to guide decision-making.
Objective
This study aims to quantify the level of inpatient thrombophilia testing and determine the extent of inappropriate testing, assessing its impact on excess costs and the quality of patient care in the inpatient setting. We also aim to study the frequency in which patients for whom thrombophilia is suspected follow up with outpatient hematology for further testing, monitoring, and treatment. The target audience includes hospital leadership, attending physicians, and resident physicians of all specialties.
Methods
Laboratory orders at our urban, academic hospital for Antithrombin III activity, Antithrombin III antigen, Protein C activity, Protein C antigen, Protein S activity, Factor V Leiden, and Prothrombin gene mutation were collected between January and June 2023. These data were surveyed by three independent reviewers for inpatient status, appropriateness of orders based on American Society of Hematology and American Stroke Association guidelines, ordering department, inpatient hematology consult, hematology recommendations, and any outpatient hematology follow-up. Data were analyzed by a fourth independent reviewer.
Results
A total of 116 inpatients had thrombophilia lab studies ordered during their hospitalization. Of these, 67 (58%) had any inappropriate orders placed. Nine patients (7.8%) were undergoing expedited transplant or ventricular assist device evaluations. Ninety cases had hematology consulted inpatient either before or after the studies were ordered, but only 5% of these cases had thrombophilia workups recommended or approved by hematology. Services who ordered the testing included: neurology, internal medicine, cardiology, general surgery, obstetrics/gynecology, medical intensive care unit, vascular surgery, hematology, nephrology, and emergency medicine. Most thrombophilia workups were initiated by a neurology primary team (43 cases), followed by internal medicine (30 cases), and then by a cardiology subspecialty service (28 cases). One hundred patients (86%) had no change in care, and only two patients (1.74%) had outpatient follow-up with hematology at six months. The overall cost of inpatient thrombophilia workups was $18,187.57.
Conclusions
Most inpatient thrombophilia orders have no inpatient clinical implications and add excess cost to hospitalizations. In our urban, academic medical center, most patients did not follow up outpatient with hematology despite their inpatient teams considering a thrombophilia in the etiology of their thrombus. There should be increased education around the indications for inpatient thrombophilia workups and increased referrals to outpatient specialists if clinically warranted.
Clinical Implications
Educational initiatives geared at resident physicians will be implemented with the goal of having only clinically indicated thrombophilia workups completed inpatient and with proper outpatient follow-up coordinated.
A significant portion of the thrombophilia testing was ordered by subspecialty teams within protocols, such as within an inpatient stroke work-up order set, despite not being recommended by the American Stroke Association guidelines. Targeted interventions can be directed toward subspecialties, such as neurology, to eliminate inappropriate testing from these protocols. Furthermore, Epic Best Practice Advisories will be implemented whenever these labs are ordered inpatient that prompt a referral to an outpatient hematologist.