Introduction. Thrombophilias can occur from a variety of inherited and acquired abnormalities. Patients with these abnormalities of the coagulation pathway often have a higher propensity to develop venous thromboemboli (VTE), although the risk for developing a VTE is not dependent on the existence of an acquired or genetic abnormality. The question then remains, in the event of a VTE, when is testing indicated for a potential thrombophilic pre-disposition? The standard reasons to consider testing are to: a) Look for an underlying cause of an unprovoked VTE; b) Assess the probability of a repeat event thereby guiding duration of anticoagulation therapy; and c) Identify asymptomatic family members with an underlying predisposition to thrombophilia who might benefit from thromboprophylaxis or genetic counseling. In an effort to improve testing efficiency, the hypercoagulable panel order set (HCPAN), a set of 8 tests indicated for inherited thrombophilia, was instituted at the University of New Mexico at the outset of induction of the electronic medical record. However, we hypothesize that the HCPAN is being utilized outside of guideline-directed diagnostic utility. Methods: A list of 600 HCPAN tests from October 2012 to November 2013 was generated from the TriCore historical database. This included all adult inpatient and outpatient instances. The investigators conducted manual chart review of each patient, evaluating risk factors for VTE, the rationale for ordering the HCPAN, and the level and service of the ordering provider. The protocol was approved by the Institutional Review Board for the UNM School of Medicine. Results: Preliminary data indicate minimal correlation with ordering the test and the status of the thrombophilic event. Out of the 50 patients that were analyzed, 42% of the charts surveyed ordered the HCPAN for a VTE that was clearly provoked, despite guidelines indicating the test for unprovoked cases only. It is well known that various tests for thrombophilia are invalidated when a patient is on anticoagulation, (e.g. unfractionated Heparin); however, of patients reviewed, 71% of the panels were drawn while on one or more of these agents were present. Furthermore, 62% of HCPAN tests were ordered in the presence of an active thrombus, invalidating the results of the test. Conclusion: The data indicates that the majority of HCPAN tests are being ordered outside of recommended guidelines, either because they are being ordered for a provoked clot, in the presence of anticoagulant, or in the presence of an active clot. Furthermore, our preliminary results also indicate that the HCPAN at UNM Hospital encompasses a variety of tests which appear to have been ordered in their entirety when only a small number of tests were indicated, and that the reason for this testing was often not documented in the chart. This, along with the evidence that the majority of testing is not in accordance with current guidelines, establishes that hypercoagulability testing is an area which may benefit from a quality improvement intervention.
Zimmerberg-Helms, Jessica; Taylor Goot; Allison Burnett; and Patrick Rendon. "Effectiveness of thrombophilia testing: testing to a fault?." (2015). http://digitalrepository.unm.edu/hostpitalmed_pubs/12