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Conformance of Clinical Practice to Established Recommendations for the Diagnosis and Treatment of Venous Thromboembolic Disease: Robin Revisited

St. Francis Medical Center, Pittsburgh, Pennsylvania

Dana S. Kellis, M.D.,

Department of Internal Medicine, CONEMAUGH Memorial Hospital, Johnstown, Pennsylvania

Stephen F. Hightower, M.D.

Department of Internal Medicine, CONEMAUGH Memorial Hospital, Johnstown, Pennsylvania

Over a decade ago, Dr. Robin expressed concern regarding overdiagnosis and overtreatment of pul monary embolism. Since that time, significant ad vances have been forthcoming in the diagnosis and treatment of venous thromboembolic disease. Using Continuous Quality Improvement concepts, this study revisits Robin's concerns and assesses the conform ance of clinical practice at one institution with estab lished requirements for the diagnosis and treatment of venous thromboembolic disease to identify remain ing opportunities to improve care.

The study design is a retrospective chart review. Medical records of all patients (N = 63) discharged from a university-affiliated teaching hospital from 7/ 1/89 to 6/30/90 with a diagnosis of primary venous thromboembolic disease were studied. Requirements for the diagnosis and treatment were established through review of the medical literature. Conform ance to these requirements was assessed and de scribed. Descriptive statistics were used.

Only 7 of 63 charts (11 %) met all requirements for the diagnosis and treatment of venous thromboem bolic disease. Fifty-six charts (89%) failed to meet at least one criterion. There was no evidence of overdi agnosis of venous thromboembolic disease in patients with a discharge diagnosis of pulmonary embolism (N = 17). Eight of 62 patients (13%) demonstrated potential overdiagnosis of venous thromboembolic disease involving the lower extremities. Nine of 60 (15%) heparin therapies demonstrated significant nonconformance to recommendations. Fifty-four of 59 (91%) warfarin therapies failed to conform to recommendations. Eighty-three percent of these war farin errors were considered to be technical. How ever, 17% were determined to be clinically signifi cant. Of 5 patients treated with a transvenous filter device, 1 failed to meet therapeutic requirements. No patients received thrombolytic therapy.

A small minority of study patients met all require ments for diagnosis and treatment of venous throm boembolic disease. In patients discharged with a di agnosis of pulmonary embolism, conformance of clin ical practice to diagnostic requirements for at least one element of venous thromboembolic disease was excellent. However, significant nonconformance was demonstrated in the diagnosis of venous thromboem bolic disease of the lower extremities and in treatment with heparin, warfarin, and transvenous filter de vices. Underutilization of thrombolytic therapy is suggested.

American Journal of Medical Quality, Vol. 9, No. 4, 153-157 (1994)
DOI: 10.1177/0885713X9400900404


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