Effectiveness of interventions for the implementation of thromboprophylaxis in hospitalised patients at risk of venous thromboembolism: an updated abridged Cochrane systematic review and meta-analysis of randomised controlled trials.

To assess the effectiveness of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of venous thromboembolism (VTE) in hospitalised medical and surgical patients at risk of VTE. Systematic review and meta-analysis of randomised controlled trials (RCTs). Medline, PubMed, Embase, BIOSIS, CINAHL, Web of Science, CENTRAL, DARE, EED, LILACS and clinicaltrials.gov without language restrictions from inception to 7 January 2017, as well as the reference lists of relevant review articles. RCTs that evaluated the effectiveness of system-wide interventions such as alerts, multifaceted, education, and preprinted orders when compared with no intervention, existing policy or another intervention. We included 13 RCTs involving 35 997 participants. Eleven RCTs had data available for meta-analysis. Compared with control, we found absolute increase in the prescription of prophylaxis associated with alerts (21% increase, 95% CI [15% to 275%]) and multifaceted interventions (4% increase, 95% CI [3% to 11%]), absolute increase in the prescription of appropriate prophylaxis associated with alerts (16% increase, 95% CI [12% to 20%]) and relative risk reductions (risk ratio 64%, 95% CI [47% to 86%]) in the incidence of symptomatic VTE associated with alerts. Computer alerts were found to be more effective than human alerts, and multifaceted interventions with an alert component appeared to be more effective than multifaceted interventions without, although comparative pooled analyses were not feasible. The quality of evidence for improvement in outcomes was judged to be low to moderate certainty. Alerts increased the proportion of patients who received prophylaxis and appropriate prophylaxis, and decreased the incidence of symptomatic VTE. Multifaceted interventions increased the proportion of patients who received prophylaxis but were found to be less effective than alerts interventions. CD008201.

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Competing interests: The authors of this review have not received any funding to undertake this review other than the peer-reviewed grant noted above. The authors report the following declarations of interest: SRK has received grant support from public granting agencies (CIHR) for research on the treatment of venous thrombosis. She participated in industry-sponsored advisory board meetings (Boehringer-Ingelheim, Servier Canada, one meeting for each entity) on the treatment of venous thrombosis and provided expert testimony for the Canadian Medical Protective Association. SRK also reports that Sanofi Aventis has partnered with her institution to help create a center of excellence in thrombosis and anticoagulation. AJK-D’s institution has received funds from the Young Investigator Award from the American Society of Clinical Oncology Conquer Cancer Foundation. AJK-D reports receiving payments from Bristol Myers Squibb for lectures. JDD reports receiving funds from board memberships of Bayer, Boehringer-Ingelheim, Bristol-Myers-Squibb, Daiichi-Sankyo, Pfizer and Sanofi; consultancy fees from Actelion, Janssen Research and Development; funds for speaking at educational activities; royalties from the Merck Manual, Up-to-Date; JDD’s institution has received a grant from Boehringer-Ingelheim. JE received an honorarium for participation in a single meeting (focus group) with LEO Pharma for work unrelated to the submitted review. AR reports board membership and consultancy activities for BMS, BI, Pfizer and Bayer, and received payment for lectures from BMS, BI, Bayer and Pfizer not related to this review. AR also reports that his institution has received a CIHR grant for AIDS vascular research, and payment for development of educational presentations from BI, Bayer, BMS and Pfizer for the preparation of university-accredited symposiums and slide kits. VT has received, and currently holds grant support from the CIHR for research in venous thrombosis; has engaged in lectures sponsored by companies that manufacture anticoagulants (Leo Pharma, Bristol Myer Squibb and Pfizer); has received a grant from a manufacturer of an anticoagulant (Sanofi Aventis). MM reports receiving funds from American Academy of Clinical Toxicology for creation of search strategies for systematic reviews, and from International Team for Implantology for peer reviewing of search strategy. WG reports consultancy (Bayer Healthcare, Pfizer and Sanofi) and payment for lectures (Bayer Healthcare, Leo Pharma and Sanofi). Other support has been received by his institution from Sanofi for clinical and quality of care initiatives in thromboembolism within and outside of his institution. WG reports that these relationships in no way impacted his involvement with this Cochrane review. SRK, JDD, JE, AR, VT and WG are investigators and AJK-D is a fellow of the CanVECTOR Network; the Network receives grant funding from the Canadian Institutes of Health Research (Funding Reference: CDT-142654).