Society of Hospital Medicine – Adult Hospital Medicine
View all recommendations from this societyReleased May 27, 2022
Do not routinely prescribe VTE prophylaxis to all hospitalized patients; use an evidence-based risk stratification system to determine whether a patient needs VTE prophylaxis. If they do warrant prophylaxis, use a bleeding risk assessment to determine if mechanical rather than pharmacologic prophylaxis is more appropriate.
Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitals. Pharmacologic prophylaxis has been shown to reduce the risk of clinically significant VTE. While VTE prevention should be considered for every hospitalized patient, excess VTE prophylaxis – either prophylaxis inappropriately administered to patients at low risk of VTE or to high risk patients with contraindications – can be harmful. National guidelines recommend objective risk stratification for venous thromboembolism (VTE) prevention in hospitalized medical patients.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
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The Society of Hospital Medicine (SHM) created a Choosing Wisely® subcommittee comprised of representatives of the Hospital Quality and Patient Safety committee and included diverse representation of academic, community and adult hospitalists. SHM committee members submitted 150 recommendations for consideration, which were discussed for frequency of occurrence, the uniqueness of the tests and treatments and whether the cost burden for a specific test or treatment proved to be significant, narrowing the list to 65 items. The Choosing Wisely subcommittee ranked these items and a survey was sent to all SHM members to arrive at 11 recommendations, of which the final five were determined utilizing the Delphi method. SHM’s Board approved the final recommendations.
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These recommendations were created by the SHM Hospital Quality and Patient Safety Committee’s High Value Care Sub-Committee (HVCC).
Phase 1: Crowdsourcing and Brainstorming – An online questionnaire requesting examples of low-value care in adult hospital medicine was sent to the SHM listserv, along with ABIM Foundation and affiliated social media outlets. All examples of low-value care from the questionnaire were compiled, edited, counted, and categorized into 5 domains: laboratory, imaging, medication, diagnostics and other. Duplicate or similar recommendations were also taken into account. Recommendations in the previous SHM CW Top 5 list were removed. All items with 10 or more mentions were taken into the next phase in an effort to capture the most prominent themes.
Phase 2: Literature Search and Developing Recommendations – All items brought into this phase were individually reviewed and discussed through an iterative process. Items were divided among HVCC members, and a literature search was performed in the PubMed database. Focused recommendations were developed and presented to the committee for review. Items that were duplicative or had insufficient evidence to support the recommendation were removed, leaving 22 items.
Phase 3: Modified Delphi Voting – For the remaining recommendations, a Delphi scoring process was utilized to reach consensus among clinicians and patient advocates. A total of 7 HVCC members and 7 patient advocates voted on the recommendations.
For each recommendation on the voting survey, clinician respondents were asked to rate on a 1-5 Likert scale on three criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to hospital medicine. Patient advocates were asked to rate each recommendation based on the same Likert scale on a slightly different criteria: (1) strength of evidence, (2) potential for avoiding patient harm, and (3) relevance to patients.
SHM’s disclosure and conflict of interest policy can be found at www.hospitalmedicine.org/industry.
Sources
Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in non-surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice. Chest 2012;141(2 suppl):e1955-e2265.
Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. doi:10.1182/bloodadvances.2018022954
Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e227S–77S.
Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011; 155(9):625–632.
Stuck AK, Spirk D, Schaudt J, Kucher N. Risk assessment models for venous thromboembolism in acutely ill medical patients. A systematic review. Thromb Haemost. 2017; 117(4):801–808.
Barbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010; 8(11):2450–2457.
