Original Article A clinical decision support system for venous thromboembolism prophylaxis at a general hospital in a middle-income country*,** Sistema de suporte à decisão clínica para um programa para profilaxia de tromboembolia venosa em um hospital geral de um país de renda média Fernanda Fuzinatto, Fernando Starosta de Waldemar, André Wajner, Cesar Al Alam Elias, Juliana Fernándes Fernandez, João Luiz de Souza Hopf, Sergio Saldanha Menna Barreto Abstract Objective: To determine the impact that implementing a combination of a computer-based clinical decision support system and a program of training seminars has on the use of appropriate prophylaxis for venous thromboembolism (VTE). Methods: We conducted a cross-sectional study in two phases (prior to and after the implementation of the new VTE prophylaxis protocol) in order to evaluate the impact that the combined strategy had on the use of appropriate VTE prophylaxis. The study was conducted at Nossa Senhora da Conceição Hospital, a general hospital in the city of Porto Alegre, Brazil. We included clinical and surgical patients over 18 years of age who were hospitalized for ≥ 48 h. The pre-implementation and post-implementation phase samples comprised 262 and 261 patients, respectively. Results: The baseline characteristics of the two samples were similar, including the distribution of patients by risk level. Comparing the pre-implementation and post-implementation periods, we found that the overall use of appropriate VTE prophylaxis increased from 46.2% to 57.9% (p = 0.01). Looking at specific patient populations, we observed that the use of appropriate VTE prophylaxis increased more dramatically among cancer patients (from 18.1% to 44.1%; p = 0.002) and among patients with three or more risk factors (from 25.0% to 42.9%; p = 0.008), two populations that benefit most from prophylaxis. Conclusions: It is possible to increase the use of appropriate VTE prophylaxis in economically constrained settings through the use of a computerized protocol adhered to by trained professionals. The underutilization of prophylaxis continues to be a major problem, indicative of the need for ongoing improvement in the quality of inpatient care. Keywords: Venous thrombosis/prevention & control; Venous thromboembolism/prevention & control; Heparin/therapeutic use. Resumo Objetivo: Determinar o impacto da implantação de um sistema informatizado de suporte à decisão clínica combinado com seminários instrucionais na utilização de profilaxia para tromboembolia venosa (TEV) de forma adequada. Métodos: Estudo transversal em duas fases (antes e depois da implantação de um novo protocolo de profilaxia para TEV) para avaliar o impacto que a estratégia combinada teve na utilização adequada da profilaxia para TEV. O estudo foi conduzido no Hospital Nossa Senhora da Conceição, um hospital geral localizado em Porto Alegre (RS). Foram incluídos pacientes clínicos e cirúrgicos com mais de 18 anos com tempo de hospitalização ≥48 h. Nas fases pré e pós-implantação, foram incluídos 262 e 261 pacientes, respectivamente. Resultados: As características de base das duas amostras foram semelhantes, inclusive em relação à distribuição dos pacientes por nível de risco. Comparando-se os períodos pré e pós-implantação, verificou-se que a adequação da profilaxia para TEV aumentou de 46,2% para 57,9% (p = 0,01). Ao se observar populações específicas de pacientes, o uso adequado da profilaxia para TVE aumentou dramaticamente em pacientes com câncer (de 18,1% para 44,1%; p = 0,002) e em pacientes com três ou mais fatores de risco (de 25,0% para 42,9%; p = 0,008), populações essas que mais se beneficiam da profilaxia. Conclusões: É possível aumentar o uso de profilaxia adequada para TEV em cenários economicamente desfavoráveis através do uso de protocolos informatizados e de profissionais treinados. A subutilização da profilaxia permanece como um problema importante, destacando a necessidade da melhora continuada na qualidade da assistência hospitalar. Descritores: Trombose venosa/prevenção & controle; Tromboembolia venosa/prevenção & controle; Heparina/uso terapêutico. * Study carried out at the Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. Correspondence to: Fernanda Fuzinatto. Hospital Nossa Senhora da Conceição, Serviço de Medicina Interna. Avenida Francisco Trein, 596, Cristo Redentor, CEP 91350-200, Porto Alegre, RS, Brasil. Tel. 55 51 3357-2000. E-mail: [email protected] Financial support: None. Submitted: 21 October 2012. Accepted, after review: 7 January 2013. **A versão completa em português deste artigo está disponível em www.jornaldepneumologia.com.br J Bras Pneumol. 2013;39(2):138-146 A clinical decision support system for venous thromboembolism 139 prophylaxis at a general hospital in a middle-income country Introduction through a CDSS would increase the proportion of patients receiving appropriate prophylaxis. Venous thromboembolism (VTE) comprises two related conditions—deep-vein thrombosis Methods and pulmonary embolism—and is responsible for We devised a strategy for improving VTE a great number of complications in hospitalized prophylaxis that involved the creation of a CDSS patients. Pulmonary embolism accounts for 5-10% and the organization of training seminars. We of all deaths in hospitalized patients, making conducted a cross-sectional study in two phases VTE the most common preventable cause of (prior to and after the implementation of the in-hospital death.(1,2) new strategy) in order to assess the proportion of Prevention is the most effective strategy to patients receiving appropriate VTE prophylaxis. reduce the burden of VTE. There is considerable The study was conducted at the Nossa Senhora evidence that primary prophylaxis with heparin da Conceição Hospital, which is located in the city significantly reduces the incidence of VTE of Porto Alegre, Brazil, and is the largest general without increasing the risk of major bleeding. (3,4) hospital in the southern region of the country. The In addition, VTE prophylaxis has proven to be hospital is affiliated with the Brazilian National cost effective, reducing treatment costs and Ministry of Health and provides treatment only shortening hospital stays.(5) via the Brazilian Unified Health Care System. It Over the last decade, several guidelines is a teaching hospital, with 750 adult inpatient aimed at improving preventive strategies and beds available for use in a number of medical increasing their use have been published.(5-7) and surgical specialties, except for orthopedics, Although the majority of medical and surgical trauma, and neurosurgery. inpatients have multiple risk factors for VTE, In August of 2008, a group of physicians large prospective studies have demonstrated that from the internal medicine department was given methods of preventing VTE are underutilized. (8,9) the challenge of developing a VTE prevention In a multinational cross-sectional study, the protocol. The group created a protocol, adapted proportion of hospital patients at risk for VTE from existing guidelines, to guide the prescription ranged from 36% to 73% and the proportion of of VTE prophylaxis. The consensus guidelines patients receiving VTE prophylaxis ranged from of the American College of Chest Physicians, 2% to 84%.(10) This illustrates the difficulty of published in June of 2008,(5) was selected as translating into practice knowledge disseminated the primary source of recommendations for the in the literature. This situation has also stimulated protocol to be implemented. new research to identify possible obstacles that We reviewed the current evidence in order to limit the effectiveness of VTE prevention measures clarify areas of concern, such as major risk factors, and to evaluate strategies to implement changes.(11) contraindications, prophylaxis in post-stroke Passive strategies and isolated measures, such patients, cancer, and some types of surgery. To as the distribution of guidelines and protocols incorporate new evidence, we searched the Medline or the staging of one-time trainings, have little and Cochrane databases, as well as meeting with impact on practices, whereas the use of multiple teams of internists and other specialists to discuss strategies with tools that work at the various stages articles pertaining to their practice. To launch of knowledge dissemination has been shown to the protocol recommendations, physicians from be highly effective.(5,12,13) Computer-based clinical all departments of the hospital were invited to decision support systems (CDSSs) and computer attend a final consensus meeting. reminders are currently in use as strategies to The VTE prevention protocol established risk improve the quality of healthcare and have been factors, heparin contraindications, and appropriate especially effective for VTE prophylaxis.(14) prophylaxis measures in accordance with patient The objective of the present study was to risk of VTE. We adopted a model that could be evaluate the effects that a combined strategy of easily followed by the prescribing physician, implementing a CDSS and organizing training using a CDSS in which VTE risk was stratified seminars has on the use of appropriate VTE into three levels. Each level of VTE risk was linked prophylaxis. We hypothesized that real-time to a menu of acceptable prophylaxis options presentation of VTE prophylaxis guidelines (Chart 1). The protocol did not include trauma, J Bras Pneumol. 2013;39(2):138-146 140 Fuzinatto F, Waldemar FS, Wajner A, Elias CAA, Fernandez JF, Hopf JLS neurosurgery, or orthopedic patients. In addition, We used a two-stage approach in order to we excluded pregnant and postpartum women. implement the strategies and integrate the VTE At our hospital, unfractionated heparin (UFH) prevention protocol as a mandatory electronic and low-molecular-weight heparin (LMWH, CDSS. First, one-hour seminars were held to enoxaparin) are available for VTE prophylaxis. present the protocol, emphasizing the importance Because of the higher cost of LMWH, only UFH of prophylaxis and its indications, as well as to was included in the VTE prevention protocol, explain how the CDSS would work. Residents and given that UFH is the therapeutic equivalent of attending physicians from the various medical LMWH in terms of efficacy and safety in the specialties were invited to attend. The protocol general medical and surgical population.(5) established was then included as a standardized We estimated that, assuming a 50% prevalence VTE prevention module interfaced with the of appropriate prophylaxis in the first phase of the electronic medical records entry system of the study, two samples of at least 227 patients each hospital. would be needed in order to detect differences The standardized VTE prevention module was of at least 15% in that prevalence between the activated automatically at the second access of two periods with sufficient precision (two-tailed the electronic medical record after an admission alpha = 0.05 and beta = 0.10). or transfer between units, the first access typically In the first phase of the study, conducted being made by the admitting (staff) physician between April and July of 2009 (prior to the and the second access being by the attending implementation of the VTE prevention protocol), physician. Physicians were prompted to select the patient sample comprised 262 patients, a VTE risk level for each patient, according to whereas that of the second phase of the study, the predetermined risk profiles (Chart 1), and to conducted between December of 2009 and determine whether there were any contraindications February of 2010 (after the implementation of to pharmacologic prophylaxis. When the risk the protocol), comprised 261 patients. In both level was selected, the recommended dose of phases, the data were collected by six residents UFH was automatically added to the electronic in internal medicine, previously trained in the prescription for that patient. In patients with appropriate techniques, who reviewed patient contraindications, UFH was not included in the charts and prescription forms in order to obtain prescription and the standardized VTE prevention the pertinent data. No attending physicians were module was automatically activated every 48 hours informed of the study. in order to identify the persistence or resolution Chart 1 - Venous thromboembolism prophylaxis protocol. Risk Level Characteristics Prophylaxis Postoperative period following minor surgerya in patients who are not bedridden Low Postoperative period following laparoscopic surgery in patients Early ambulation without risk factors No acute disease or bedridden status in medical patients Postoperative period following major surgery Postoperative period following laparoscopic surgery in patients with Unfractionated heparin, Moderate risk factors 5,000 IU subcutaneously Acute disease in medical patients every 12 h Bedridden status and risk factors in medical patients Postoperative period following major surgery in patients with multiple (3 or more) risk factors Postoperative period following bariatric surgery Unfractionated heparin, High Postoperative period following major cancer surgery 5,000 IU subcutaneously Medical patients with multiple risk factors (3 or more), active every 8 h cancer, thrombophilia or previous venous thromboembolism episode. aProcedures that do not involve the opening of large cavities, risk of severe hemorrhage, or extensive dissections. J Bras Pneumol. 2013;39(2):138-146 A clinical decision support system for venous thromboembolism 141 prophylaxis at a general hospital in a middle-income country of the contraindication. The physician could Results also choose not to use prophylaxis in patients on anticoagulation. Physicians who chose not Except for a few risk factors, the baseline to follow the protocol recommendations were characteristics of the patients were similar in required to fill out a form justifying that choice. the two phases of the study (Table 1). The The main outcome measure was an distribution of the patients by risk level was also increase in the proportion of patients receiving similar between the two phases. In the first and appropriate VTE prophylaxis, comparing the second phases, respectively, 21.4% and 20.3% pre-implementation and post-implementation of patients were postoperative patients, those periods. In both phases, patients were randomly having undergone major surgery accounting for 66% and 45%, respectively. selected from among those admitted to the Nearly all of the patients included in the medical or surgical wards, including the ICU. study were classified as being at moderate or Randomization was performed by drawing bed high risk of VTE (43.4% and 55.4%, respectively). numbers, with the number of beds used in each The main contraindications were coagulopathy, specialty proportional to the ratio between the active bleeding, and active peptic ulcer disease. number of beds available to that specialty and No other contraindications were identified. the total number of beds in the hospital. The Comparing the pre-implementation and inclusion criteria were being over 18 years of post-implementation data, we found that the age and having been hospitalized for ≥ 48 h use of appropriate VTE prophylaxis increased on any of the wards. The exclusion criteria were from 46.2% to 57.9% (Table 2). The absolute current anticoagulation, pregnancy, puerperium, difference between the two study periods was and a history of acute thromboembolic disease. 11.7% (95% CI: 3.2% to 20.3%), which was The main variables studied, the risk factors, statistically significant (p = 0.01). and the contraindications are cited in a previously In cancer patients, the use of appropriate published article.(15) Each prescription was classified VTE prophylaxis increased from 18.1% in as appropriate or inappropriate on the basis of the pre-implementation phase of the study whether it followed the protocol, after considering to 44.1% in the post-implementation phase the patient risk of VTE and the presence of (absolute difference, 26%; 95% CI: 9.9% to contraindications to heparin. Two of the authors 42.3%; p = 0.002). As can be seen in Table assessed the appropriateness of prophylaxis, 2, a significant increase was also observed in and questionable cases were discussed by the patients with multiple risk factors (from 25.0% research group as a whole. to 42.9%; absolute difference, 17.9%; 95% CI: Patients were stratified by medical or surgical 4.8-30.9%; p = 0.008). In addition, there was ward and by the risk of VTE (low, medium, or a post-implementation increase in the use of high). The absolute difference in the proportion appropriate VTE prophylaxis in patients at high of patients receiving appropriate VTE prophylaxis risk of VTE (Table 3). Among surgical patients in between the two periods and the 95% confidence the postoperative period (defined as those who had interval for that difference were calculated for undergone a surgical procedure in the last 30 days), each stratum. Comparisons between the two there was a small post-implementation increase in periods in terms of the clinical characteristics of the use of appropriate VTE prophylaxis (from 53.6% the patients were tested using the chi-square test to 60.4%), which was not statistically significant or t-test, as appropriate. The analysis included (absolute difference, 6.8%; 95% CI: −13.6% all eligible patients. Values of p < 0.05 were to 27.2%; p = 0.6). However, among medical considered statistically significant. All data were patients, there was a significant improvement analyzed using the Statistical Package for the (from 44.2% to 57.2%; absolute difference, 13%; Social Sciences, version 17.0 (SPSS Inc., Chicago, 95% CI: 3.0% to 23.1%; p = 0.011). IL, USA), and WINPEPI, version 11.4 (http:// www.brixtonhealth.com/pepi4windows.html). Discussion The study was approved by the Research Ethics Committee of the Nossa Senhora da Conceição Our study demonstrates that the Hospital, and all of the authors signed a data implementation of a CDSS accompanied by use agreement. training seminars had a positive effect on the J Bras Pneumol. 2013;39(2):138-146 142 Fuzinatto F, Waldemar FS, Wajner A, Elias CAA, Fernandez JF, Hopf JLS Table 1 - Characteristics of the patients included in the two phases of the study. Phase 1a Phase 2b Characteristic p (n = 262) (n = 261) Age, mean ± SD 59.1 ± 16.6 52.2 ± 17.1 0.539 Male gender, n (%) 137 (52.3) 138 (52.9) 0.963 Postoperative patients, n (%) 56 (21.4) 53 (20.3) 0.847 Major specialties, n (%) Internal medicine 58 (22.1) 51 (19.5) 0.855 Medical specialties 102 (38.9) 110 (42.1) General surgery 35 (13.4) 37 (14.2) Surgical specialties 50 (19.1) 50 (19.2) Gynecology 17 (6.5) 13 (5) VTE risk, n (%) High 143 (54.6) 147 (56.3) 0.626 Moderate 117 (44.7) 110 (42.1) Low 2 (0.8) 4 (1.5) Risk factors, n (%) Immobilization 185 (70.6) 219 (83.9) < 0.0001* Infection 116 (44.3) 136 (52.1) 0.88 Active cancer 72 (27.5) 68 (26.1) 0.787 Use of a central venous catheter 35 (13.4) 56 (21.5) 0.020* Major surgery 37 (14.1) 24 (9.2) 0.105 Severe lung disease 20 (7.6) 25 (9.6) 0.524 Heart failure 21 (8) 23 (8.8) 0.864 Acute myocardial infarction 22 (8.4) 8 (3.1) 0.015* Stroke 13 (5) 24 (9.2) 0.86 Limb paralysis/paresis 21 (8) 21 (8) 1 ICU admission 16 (6.1) 17 (6.5) 0.991 Obesity BMI 30-35 kg/m2 45 (17.2) 27 (10.3) 0.032* BMI > 35 kg/m2 16 (6.1) 17 (6.5) 0.991 Chemotherapy/radiotherapy 7 (2.7) 14 (5.4) 0.179 History of VTE 3 (1.1) 11 (4.2) 0.57 Use of oral contraceptives 3 (1.1) 3 (1.1) 1 Use of hormone replacement therapy 2 (0.8) 3 (1.1) 0.686 Myeloproliferative disease 5 (1.9) 1 (0.4) 0.216 Inflammatory bowel disease 0 (0) 2 (0.8) 0.249 Contraindications, n (%) Coagulopathy 10 (3.8) 17 (6.5) 0.232 Active peptic ulcer disease 2 (0.8) 0 (0) 0.499 Active bleeding 13 (5) 8 (3.1) 0.378 VTE: venous thromboembolism; and BMI: body mass index. aFrom April through July of 2009 (prior to the implementation of the VTE prevention protocol). bFrom December of 2009 through February of 2010 (after the implementation of the VTE prevention protocol). *< 0.05 (statistically significant). practices of physicians, increasing the proportion measures to improve VTE prophylaxis. Neither of patients receiving appropriate prophylaxis sample included patients classified as being at for VTE. very high risk of VTE (orthopedic, neurosurgery, Our samples were representative of the risk and trauma patients), because such patients profile of the patients seen at our hospital, most of are not treated at our hospital. Most of the whom are classified as being at moderate to high patients admitted to our hospital are referred risk of VTE, underscoring the need to implement from emergency rooms, which leaves few beds J Bras Pneumol. 2013;39(2):138-146 A clinical decision support system for venous thromboembolism 143 prophylaxis at a general hospital in a middle-income country Table 2 - Use of appropriate venous thromboembolism prophylaxis in the two phases of the study. Phase 1a Phase 2b Difference Category Absolute N Total % N Total % 95% CI p (%) All patients 121 262 46.2 151 261 57.9 11.7 3.2-20.3 0.01* Patients with cancer 13 72 18.1 30 63 44.1 26 9.9-42.3 0.002* Patients with 3 or 26 104 25 51 119 42.9 17.9 4.8-30.9 0.008* more risk factors aFrom April through July of 2009 (prior to the implementation of the venous thromboembolism prevention protocol). bFrom December of 2009 through February of 2010 (after the implementation of the venous thromboembolism prevention protocol). *< 0.05 (statistically significant). Table 3 - Use of appropriate venous thromboembolism prophylaxis according to patient risk level. Phase 1 (Before) Phase 2 (After) Difference VTE risk Absolute N Total % N Total % 95% CI p % High 32 143 22.4 63 147 42.9 20.5 9.3 to 31.7 0.0001* Moderate 88 117 75.2 85 110 77.3 2.1 −9.9 to 14.0 0.835 Low 1 2 50 3 4 75 25 −93.0 to 100.0 1 VTE: venous thromboembolism. *< 0.05 (statistically significant). available for elective admissions. This explains and simple enough for everyday use. Possible the low number of low-risk patients in our errors include listing options for VTE prophylaxis samples. The increase in the use of appropriate without providing any guidance about which VTE prophylaxis was most pronounced among choice is most appropriate or desirable, as well patients with cancer and among patients with as supplying too much information, making the three or more VTE risk factors, populations that protocol too complicated. Some order sets offer benefit the most from such prophylaxis. four to six levels of VTE risk, but the evidence Various health advocacy groups have to distinguish the levels of risk, as well as the recommended measures of prophylaxis for VTE. differences among the types of prophylaxis, is Such recommendations include evaluating VTE often weak. Two to three levels of VTE risk are risk for every patient at admission and regularly sufficient.(17) Another possible error is to offer during hospitalization, especially after transfer to non-pharmacologic VTE prophylaxis as a first- the ICU.(16) Considering these recommendations, line option in patients without contraindications the CDSS created in our hospital is automatically to pharmacological methods. activated at the second access of the electronic In the creation of our protocol, we considered medical record after an admission or transfer all these possible errors and built a concise tool between units (i.e., the first access by the attending that allows physicians to make a quick decision. In physician). In addition, it is triggered whenever addition, because risk level and contraindications it detects that heparin has not been prescribed. change frequently in acutely ill patients, a link There are studies currently underway that to the protocol was permanently available in are aimed at identifying the characteristics that the electronic record for re-evaluation. When make a protocol effective. Protocols for VTE contraindications were reported, the protocol prophylaxis should consider many aspects of was automatically triggered for reassessment the decision-making process: VTE risk factors; within 48 h. the primary illness (cause of hospitalization); Several studies have attempted to demonstrate patient immobilization; and the type of surgery the improvement in the appropriateness of VTE the patient is scheduled to undergo. Considering prophylaxis after implementation of various these aspects, protocols should include many strategies. In a randomized controlled trial features and yet must keep things efficient involving 6,371 hospitalized patients, the use of J Bras Pneumol. 2013;39(2):138-146 144 Fuzinatto F, Waldemar FS, Wajner A, Elias CAA, Fernandez JF, Hopf JLS electronic alerts has increased the use of heparin and the lack of a control population. We studied from 18.9% to 32.2%.(18) In a French study of two populations sequentially, and it is therefore orthopedic patients, the use of electronic alerts possible that some unrecognized temporal trend increased the adherence to guidelines from 82.8% biased our results. We cannot exclude hidden to 94.9%.(19) Kucher et al. demonstrated that the confounding factors. Data were obtained from application of a CDSS reduces the rates of deep reviews of patient charts, making it difficult vein thrombosis and pulmonary embolism.(20) to control for differences in data collection. To our knowledge, ours is the first study In addition, we evaluated the effects of the to report testing the effects of a CDSS for VTE implementation of the protocol only in terms of prophylaxis in a middle-income country. In Brazil, the proportional use of appropriate VTE prophylaxis studies conducted in the cities of São Paulo(21) and did not evaluate patient outcomes. However, and Salvador(22) showed that the distribution of some authors now consider it preferable to evaluate written guidelines for physicians was not effective processes rather than outcomes when assessing in increasing adherence to prophylactic measures. quality of care.(26) A meta-analysis that evaluated the effectiveness Although the use of a CDSS increases the of different strategies to increase adherence use of appropriate VTE prophylaxis, it is still to prophylactic measures for VTE also showed far from optimal. Even with a simple and quick that passive measures, such as the distribution tool, the erroneous evaluation of the risk factors of guidelines, were ineffective.(13) The authors and contraindications can lead the physician to of that study found that the use of multiple misclassify the level of the patient risk and make strategies is more effective than is that of either an inappropriate choice regarding the prophylaxis. strategy in isolation. Among the studies evaluated Another major limitation of our study is the in that meta-analysis, there were five that had fact that we used a protocol that was developed rates of adherence to guidelines of more than locally from the current guidelines and was not 90%. All five of those studies utilized interactive validated prospectively. In the literature, there are processes of audit and feedback, as well as many models to assess VTE risk, most of which incorporating warning systems as reminders of have yet to be validated and are complex. (27) VTE risk assessment.(13) Kawamoto et al. identified Maynard et al. recently published a study validating characteristics of systems that are predictive of a model of risk stratification for VTE.(28) The effective decision support: generating decision authors demonstrated that a simple model with support automatically as part of the normal three levels of risk, implemented through a CDSS, clinical workflow, at the time and place of decision accompanied by educational measures, audit, and making; using computers to deliver support; and feedback, increased the use of appropriate VTE offering specific recommendations rather than prophylaxis from 58% to 98% over a three-year mere assessments. The authors found that 94% period and reduced the number of thromboembolic of CDSSs presenting those characteristics were events occurring at the hospital under study.(28) successful in improving physician practices.(12) The results of our study show that it is Our strategy involved the use of UFH for possible to increase the use of appropriate VTE two main reasons. First, patients at very high prophylaxis at a general hospital in a middle- risk of VTE, for whom the evidence of LMWH income country by implementing a CDSS and by superiority is more robust, are not admitted to educating the hospital staff. The same CDSS might our hospital. Second, although economic analyses be useful at other institutions, if the software have marginally favored the use of enoxaparin,(23,24) were adapted to local conditions. Our findings there have been no similar analyses of VTE suggest that other hospitals in Brazil should prevention in the context presented here—only consider implementing a CDSS to increase the use studies addressing the treatment of an established of VTE prophylaxis, given that studies evaluating thromboembolism.(25) Our local evaluations, the use of non-computerized protocols have focusing on hospital costs, support the use of shown that such protocols provide no benefit.(21,22) UFH, mainly due to considerable differences in The underutilization of VTE prophylaxis remains terms of drug acquisition costs. a major problem. Although the strategy employed Our study has several limitations. The major in the present study produced significant results, limitation is inherent in the observational design it is still less than ideal and calls for ongoing J Bras Pneumol. 2013;39(2):138-146 A clinical decision support system for venous thromboembolism 145 prophylaxis at a general hospital in a middle-income country staff training, as well as constant improvement 10. Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, of the CDSS. Kakkar AK, Deslandes B, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Acknowledgments Lancet. 2008;371(9610):387-94. 11. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, We would like to thank Dr. Paulo Bobek for Thomson MA. Closing the gap between research and providing continuous institutional support for practice: an overview of systematic reviews of interventions this endeavor. 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Am J medical patient. J Hosp Med. 2006;1(3):168-76. Surg. 2010;199(1 Suppl):S3-10. 25. Argenta C, Ferreira MA, Sander GB, Moreira LB. Short- 28. Maynard GA, Morris TA, Jenkins IH, Stone S, Lee J, term therapy with enoxaparin or unfractionated heparin Renvall M, et al. Optimizing prevention of hospital- for venous thromboembolism in hospitalized patients: acquired venous thromboembolism (VTE): prospective utilization study and cost-minimization analysis. Value validation of a VTE risk assessment model. J Hosp Med. Health. 2011;14(5 Suppl 1):S89-92. 2010;5(1):10-8. About the authors Fernanda Fuzinatto Preceptor for the Internal Medicine Residency Program. Nossa Senhora da Conceição Hospital and Porto Alegre Hospital de Clínicas, Porto Alegre, Brazil. Fernando Starosta de Waldemar Physician Head of Quality Improvement Projects. Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. André Wajner Preceptor for the Internal Medicine Residency Program. Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. Cesar Al Alam Elias Internist. Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. Juliana Fernándes Fernandez Internist. Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. João Luiz de Souza Hopf Internist. Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil. Sergio Saldanha Menna Barreto Full Professor. Department of Internal Medicine, Federal University of Rio Grande do Sul School of Medicine, Porto Alegre, Brazil. J Bras Pneumol. 2013;39(2):138-146