2. CHRIS KOWALSKY
FACULTY ADVISOR
ANKUR TYAGI SRIKANTH GURUJU DHRUVIKA KOHLI
PROJECT MANAGER TECHNICAL ARCHITECT QUALITY ASSURANCE
MANAGER
THE TEAM MAKING IT HAPPEN
MITHUN MATHEW
RISK & DOCUMENTATION
MANAGER
YUCHEN ZHANG
FINANCIAL MANAGER
PROJECT LIAISON
SUE SKLEDAR
UPMC/PITT
PHARMACY ADVISOR
ROY SMITH DAWN SALERNO JAMES WAGNER
UPMC PHYSICIAN
CONTENT EXPERT
DATA ANALYTICS TEAM DATA ANALYTICS TEAM
COLLEEN CULLEY
UPMC/PITT PHARMACY
SPECIALIST
ANNE DOCIMO
UPMC PHYSICIAN
ADMINISTRATIVE LEAD
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UPMC VTE 3.0
4. BACKGROUND OF PROJECT
o Patient population: elective Total Hip and Total Knee Arthroplasty (THA/TKA) surgeries at UPMC from 2012-2014
o When a blood clot occurs, breaks loose or travels in the blood, this is called Venous Thromboembolism (VTE) -
Affects patients who underwent orthopedic surgery, due to stasis of blood
o VTE may occur after TKA/THA if the patient is non-ambulatory for a prolonged period due to stasis of blood - they
are put on a prophylactic regimen as a preventive measure
o The prophylactic regimen may lead to bleeding
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UPMC VTE 3.0
5. Determining the true rate of
bleed and clot on 2012-2014
patient surgery data.
Performing comparative analysis
of bleed/clot vs non-bleed/non clot
population on the basis of
demographics, physical therapy,
and patient risk for bleeding or
clot as defined by the HAS-BLED
and CHADS2 scoring mechanism.
Performing a comparative analysis
on the effectiveness and
safety of different prophylactic
anticoagulant agents used for
VTE
BLEED & CLOT RATE COMPARATIVE ANALYSIS
PROPHYLACTIC
ANTICOAGULANT AGENTS
PROJECT SCOPE
5
UPMC VTE 3.0
6. 01. REVAMPED CRITERIA
Refine and run VTE 2.0 clot and bleed
criteria on 2012-2014 data
03. COMMON CHARACTERISTICS
Identify the common characteristics
amongst patients who bled or clotted
02. RISK SCORES
Assign CHADS2 and HAS-BLED to all the
patients after completion of labeling
04. ANTICOAGULANTS
Determine which anticoagulant is least
associated with postoperative clotting and
bleeding in this dataset
OBJECTIVES
6
UPMC VTE 3.0
12. COMPARATIVE ANALYSIS
CRITERIA
BLEED CRITERIA VTE 1.0
CRITERIA DESCRIPTION SOURCE FILE LABEL STATUS
VTE Prophylaxis Reversal
Agents
KCentra (PCC), rVIIa (NovoSeven),
Vitamin K (Phytonadione)
Charges Definite Label
Packed Red Blood Cells
Receive >= 2 units, not including the
day of surgery
Charges Definite Label
Bleeding Readmission 58 diagnosis codes Diagnoses Definite Label
Hemoglobin Drop
Drop in hemoglobin >= 2 units in 48
hours after the surgery
Labs Definite Label
Bleeding Keywords EMR: Discharge Summary
Potential Label, referenced with
manual examination of the EMR text
Bleeding Procedures 4 Procedure Codes Procedures
Potential Label, referenced with
bleeding keywords
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UPMC VTE 3.0
13. COMPARATIVE ANALYSIS
CRITERIA
BLEED CRITERIA VTE 2.0
CRITERIA DESCRIPTION SOURCE FILE LABEL STATUS
A Packed Red Blood Cells Receive >= 1 units, after 2 days of surgery Charges Definite Label
B
Bleeding related Diagnosis
Code during Hospital Stay
50 diagnosis codes Diagnoses Definite Label
C Hemoglobin Drop
Drop in hemoglobin >= 2 units in 48 hours after
the surgery
EMR Definite Label
D Bleeding Procedures One Procedure Code: 99.04 Procedures Definite Label
Final Criteria:
A patient has satisfied either Criteria A or C
AND
has satisfied Criteria B or D
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UPMC VTE 3.0
14. COMPARATIVE ANALYSIS
CRITERIA
BLEED CRITERIA VTE 3.0
CRITERIA DESCRIPTION SOURCE FILE LABEL STATUS
A Packed Red Blood Cells
Receive >= 2 units, after the Hgb drop date till 15 days
after surgery
Charges Definite Label
B
Bleeding related Diagnosis
Code during Hospital Stay
51 diagnosis codes Diagnoses Definite Label
C Hemoglobin Drop
Drop in hemoglobin >= 2 units, between a window of 2
days to 15 days after surgery
EMR Definite Label
D Bleeding Procedures One Procedure Code: 99.04 Procedures Definite Label
‘All’ Bleed Criteria:
A patient has satisfied either Criteria A or C
AND
has satisfied Criteria B or D
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UPMC VTE 3.0
15. VTE 3.0
BLEED ANALYSIS FLOWCHART
BLEED RESULT
CRITERIA
MASTER
CHARGE CODES
FILTER
DIAGNOSIS CODES
FILTER
PROCEDURE CODES
FILTER
HGB DROP
PRE-MEDS INFO
DEMOGRAPHICS
DIAGNOSES
CHARGES
PROCEDURES
EMR
H&P
RAW DATA DATA CLEANING ANALYSIS
15
UPMC VTE 3.0
16. B
D
A
C
A list of 51 diagnosis codes suggested by UPMC which are
relevant to identifying bleed patients
One procedure code: 99.04 Packed Cell Transfusion
A list of 13 charge codes including Red Blood Cell (RBC)
transfusion and fresh frozen plasma (FFP) related codes
The drop in hemoglobin (HGB) after surgery
‘ALL’ BLEED
VTE 3.0
BLEED CRITERIA
AND
A. CHARGE
CODES
OR
C. HGB DROP
B. DIAGNOSIS
CODES
D. PROCEDURE
CODE
OR
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UPMC VTE 3.0
17. MAJOR BLEED
In addition to ‘All’ Bleed criteria, ensure that the
patient was administered RBC and/or FFP
ONLY after the HGB drop
VTE 3.0 BLEED CRITERIA
ALL BLEED
CRITERIA
MAJOR BLEED
TRANSFUSION
OCCURS AFTER
HGB DROP
AND
UPMC VTE 3.0
17
‘ALL’ BLEED WINDOW MAJOR BLEED WINDOW
18. MAJOR BLEED
In addition to ‘All’ Bleed criteria, ensure that the
patient was administered RBC and/or FFP
ONLY after the HGB drop
VTE 3.0 BLEED CRITERIA
ALL BLEED
CRITERIA
MAJOR BLEED
TRANSFUSION
OCCURS AFTER
HGB DROP
AND
POST-OP ANEMIA
In addition to ‘All’ Bleed criteria, ensure that the
diagnosis code 285.1 is associated with the
patient.
ALL BLEED
CRITERIA
POST-OP ANEMIA
DIAGNOSIS
CODE 285.1AND
MINOR BLEED
The rest of the patients identified by ‘All’ Bleed
criteria who do not belong to Major Bleed or
Minor Bleed criteria.
ALL BLEED
CRITERIA
MINOR BLEED
NOT MAJOR
BLEED
AND
NOT POST-OP
ANEMIA
AND
UPMC VTE 3.0
18
19. COMPARATIVE ANALYSIS
RESULTS
PROJECT ITERATION TOTAL PATIENTS BLEED BLEED % OVER IDENTIFICATION %
VTE 1.0 8173 981 12% 780.00%
VTE 2.0 8772 463 5.28% 83.70%
VTE 3.0 16343 616 3.77% 28.69%
* 226 patients are common to both THA and TKA
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UPMC VTE 3.0
20. VTE 3.0 DATA
No - Bleed
6136
(96.37%)
Bleed
231
(3.63%)
THA
No - Bleed
9591
(96.14%)
Bleed
385
(3.86%)
TKA
‘ALL’ BLEED DISTRIBUTION
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UPMC VTE 3.0
Overall Bleed Percentage: 3.77%
* Patient data from 2012 - 2014
* 226 patients are common to both THA and TKA
21. VTE 3.0 DATA
TYPE OF BLEED MAJOR BLEED MINOR BLEED POST-OP ANEMIA
THA 8 35 195
TKA 20 63 318
TYPE OF BLEED
* Patient data from 2012 - 2014
* 226 patients are common to both THA and TKA
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UPMC VTE 3.0
22. VTE 3.0 DATA
CONFUSION PREDICTED
MATRIX No - Bleed Bleed
ACTUAL
No - Bleed 233 61
Bleed 16 11
THA BLEED CONFUSION MATRIX
22
UPMC VTE 3.0
CONFUSION PREDICTED
MATRIX No - Bleed Bleed
ACTUAL
No - Bleed 130 110
Bleed 9 26
TKA BLEED CONFUSION MATRIX
* Patient data from 2012 - 2014
* 226 patients are common to both THA and TKA
* ACTUAL: The data labeled by chart review
* PREDICTED: The data labeled by VTE 3.0 criteria
25. VTE 3.0 DATA
MER 1/657
PAS 2/1480
SHY 2/2529
SMH 18/2060
MAJOR BLEED COUNTS BY HOSPITAL
MER 1/313
MWH 1/1234
SHY 3/2395
SMH 3/950
THATKA
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UPMC VTE 3.0
27. UPMC VTE 3.0
VTE 3.0 DATA
NumberofBleedPatients
0
35
70
105
140
%ofPatientswhoBled
0.00%
2.00%
4.00%
6.00%
8.00%
A B C D E F G H
POST-OPERATIVE MEDICATIONS vs ‘ALL’ BLEED RATIO - THA
A ASPIRIN 81MG TAB
27
‘All’ Bleed 34 42 115 139 24 17 13 0
No Bleed 410 640 1772 2148 1165 1410 2148 2
Bleed% 7.66 6.16 6.09 6.08 2.02 1.19 0.6 0
Post-Operative Medications
B FONDAPARINUX 2.5MG INJ
C WARFARIN
D ENOXAPARIN
E ASPIRIN 325 MGTAB
F RIVAROXABAN 10MG TAB
G HEPARIN 5000 UNITS/ML
H APIXABAN 2.5MG TAB
28. UPMC VTE 3.0
VTE 3.0 DATA
NumberofBleedPatients
0
75
150
225
300
%ofPatientswhoBled
0.00%
5.00%
10.00%
15.00%
20.00%
A B C D E F G H
POST-OPERATIVE MEDICATIONS vs ‘ALL’ BLEED RATIO - TKA
A HEPARIN 5000 UNITS/ML
28
‘All’ Bleed 14 278 252 43 44 49 60 0
No Bleed 59 3655 3729 688 1037 1188 2539 3
Bleed% 19.18 7.07 6.33 5.88 4.07 3.96 2.31 0
Post-Operative Medications
B WARFARIN
C ENOXAPARIN
D APIXABAN 81MG TAB
E ASPIRIN 325 MG TAB
F FONDAPARINUX 2.5MG INJ
G RIVAROXABAN 10MG TAB
H APIXABAN 2.5MG TAB
29. VTE 3.0 DATA
DISTRIBUTION OF POST-OPERATIVE MEDICATIONS BY HOSPITAL - MAJOR BLEED THA
29
UPMC VTE 3.0
30. VTE 3.0 DATA
DISTRIBUTION OF POST-OPERATIVE MEDICATIONS BY HOSPITAL - MAJOR BLEED TKA
30
UPMC VTE 3.0
35. COMPARATIVE ANALYSIS
CRITERIA
CLOT CRITERIA VTE 1.0
CRITERIA DESCRIPTION SOURCE FILE LABEL STATUS
VTE treatment drugs
Enoxaparin, Fondaparinux, Heparin
in designated dosages
Charges Definite Label
Clotting readmission
ICD9 codes related to clot as
readmission cause
Diagnoses Definite Label
Thrombolytics drugs Alteplase Charges
Potential label, corroborated with
clotting keywords
IVC Filter
Drop in hemoglobin >= 2 units in 48
hours after the surgery
Labs
Potential label, corroborated with
clotting keywords
Clotting Keywords EMR: Discharge Summary
Potential Label, corroborated with
manual examination of the EMR text
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UPMC VTE 3.0
36. COMPARATIVE ANALYSIS
CRITERIA
CLOT CRITERIA VTE 2.0
CRITERIA DESCRIPTION SOURCE FILE
A VTE treatment drugs
Enoxaparin > 40mg or
Fondaparinux > 2.5mg or
Heparin >= 25000 units
In one of the date after surgery
Charges
B Clotting Diagnosis Code ICD9 codes related to clot Diagnoses
C Doppler Positive The description of Doppler file specifically mentioned clot Doppler
Final Criteria
1. A patient satisfied Criteria A and B
2. A patient satisfied either Criteria A or B, and also satisfied Criteria C at the same time
36
UPMC VTE 3.0
37. COMPARATIVE ANALYSIS
CRITERIA
CLOT CRITERIA VTE 3.0
37
UPMC VTE 3.0
Charges Codes
Filter
Diagnosis Codes
Filter
Doppler Records
CT Records
MASTER FILE
DECISION TREE
BLACK BOX
Clotted Patients Non-Clotted Patients
38. VTE 3.0
CLOT ANALYSIS FLOWCHART
LABELED DATA UNLABELED DATA
CLOT RESULT
TRAIN TEST
DEMOGRAPHICS
DIAGNOSES
CHARGES
PROCEDURES
DEMO_DIAG
DEMO_DIAG_
CHARGES
ACCT_ID
MRN_ID
MRN_ID
MASTER
ALGORITHM
RAW DATA DATA CLEANING ANALYSIS
38
UPMC VTE 3.0
39. COMPARATIVE ANALYSIS
CLOT RESULTS
PROJECT ITERATION TOTAL PATIENTS CLOT CLOT % OVER IDENTIFICATION %
VTE 1.0 8173 187 2.29% 61%
VTE 2.0 8772 100 1.14% 22%
VTE 3.0 16343 136 0.83% 2.34%
* 226 patients are common to both THA and TKA
39
UPMC VTE 3.0
40. VTE 3.0 DATA
No - Clot
6344
(99.64%)
Clot
23
(0.63%)
THA
No - Clot
9863
(98.87%)
Clot
113
(1.13%)
TKA
CLOT DISTRIBUTION
40
UPMC VTE 3.0
41. VTE 3.0 DATA
CONFUSION PREDICTED
MATRIX No - Clot Clot
ACTUAL
No - Clot 54 2
Clot 5 4
THA CLOT CONFUSION MATRIX
41
UPMC VTE 3.0
CONFUSION PREDICTED
MATRIX No - Clot Clot
ACTUAL
No - Clot 81 3
Clot 16 48
TKA CLOT CONFUSION MATRIX
* Patient data from 2012 - 2014
* 226 patients are common to both THA and TKA
45. UPMC VTE 3.0
VTE 3.0 DATA
NumberofClottedPatients
0
10
20
30
40
%ofPatientswhoClotted
0.00%
0.45%
0.90%
1.35%
1.80%
A B C D E F G H
POST-OPERATIVE MEDICATIONS vs CLOT RATIO - THA
A WARFARIN
45
Clot 34 22 1 11 2 1 2 0
No_Clot 1853 1423 86 2276 680 443 1187 2
Clot% 1.8 1.52 1.15 0.48 0.29 0.23 0.17 0
Post-Operative Medications
B RIVAROXABAN 10MG TAB
C HEPARIN 5000 UNITS/ML
D ENOXAPARIN
E FONDAPARINUX 2.5MG INJ
F ASPIRIN 81MG TAB
G ASPIRIN 325 MG TAB
H APIXABAN 2.5MG TAB
46. UPMC VTE 3.0
VTE 3.0 DATA
NumberofClottedPatients
0
50
100
150
200
%ofPatientswhoClotted
0.00%
3.50%
7.00%
10.50%
14.00%
A B C D E F G H
POST-OPERATIVE MEDICATIONS vs CLOT RATIO - TKA
A HEPARIN 5000 UNITS/ML
46
Clot 9 195 16 24 50 22 6 0
No_Clot 64 3738 715 1213 3902 2577 1075 3
Clot% 12.33 4.96 2.19 1.94 1.27 0.85 0.56 0
Post-Operative Medications
B WARFARIN
C ASPIRIN 81MG TAB
D FONDAPARINUX 2.5MG INJ
E ENOXAPARIN
F RIVAROXABAN 10MG TAB
G ASPIRIN 325 MG TAB
H APIXABAN 2.5MG TAB
56. CLINICAL FINDINGS
56
UPMC VTE 3.0
‘ALL’ BLEED TKA THA
MOST INEFFECTIVE MEDICATIONS PRIOR
TO SURGERY
ASPIRIN + ENOXAPARIN + WARFARIN +
DABIGATRAN
HEPARIN + WARFARIN
MOST INEFFECTIVE POST-OPERATIVE
MEDICATIONS
HEPARIN 5000 UNITS/ML
(19.18% BLEED RATE)
ASPIRIN 81 MG TAB
(7.66% BLEED RATE)
MOST EFFECTIVE POST-OPERATIVE
MEDICATIONS
FONDAPARINUX 2.5 MG INJ
(3.96% BLEED RATE)
AND
RIVAROXABAN 10 MG TAB
(2.31% BLEED RATE)
RIVAROXABAN 10 MG TAB
(1.19% BLEED RATE)
AND
HEPARIN 5000 UNITS/ML
(0.6% BLEED RATE)
AVERAGE LENGTH OF STAY(IN DAYS)
(4 Days Across Hospitals)
PUH : 12 - BLEED, 5 - NO BLEED
SHY : 7 - BLEED, 3 - NO BLEED
MER : 7 - BLEED, 4 - NO BLEED
PUH : 6 - BLEED, 6 - NO BLEED
57. CLINICAL FINDINGS
57
UPMC VTE 3.0
CLOT TKA THA
MOST INEFFECTIVE MEDICATIONS PRIOR
TO SURGERY
ASPIRIN + APIXABAN
HEPARIN + WARFARIN + ENOXAPARIN +
RIVAROXABAN
MOST INEFFECTIVE POST-OPERATIVE
MEDICATIONS
HEPARIN 5000 UNITS/ML
(12.33% CLOT RATE)
AND
WARFARIN
(4.96% CLOT RATE)
WARFARIN
(1.8% CLOT RATE)
MOST EFFECTIVE POST-OPERATIVE
MEDICATIONS
RIVAROXABAN 10 MG TAB
(0.85% CLOT RATE)
AND
ASPIRIN 325 MG TAB
(0.56% CLOT RATE)
ASPIRIN 81 MG TAB
(0.23% CLOT RATE)
AND
ASPIRIN 325 MG TAB
(0.17% CLOT RATE)
AVERAGE LENGTH OF STAY(IN DAYS)
(4 Days Across Hospitals)
MCH : 7 - CLOT, 2 - NO CLOT
MER : 7 - CLOT, 3 - NO CLOT
MER : 7 - CLOT, 4 - NO CLOT
PAS : 12 - CLOT, 4 - NO CLOT
58. DATA INCONSISTENCY
58
UPMC VTE 3.0
H&P File
o Search for the ‘medications prior to surgery’ for every patient in data set
o Difficult to extract medications just on the basis of keywords
Unstructured EMR File
o Search for the keywords ‘Doppler’ and ‘CT’ under the tab named ‘RAD’ (for radiology files)
o Manually search for the positive or negative keywords for ‘Thromboembolism’
59. DATA INCONSISTENCY
59
UPMC VTE 3.0
H&P File
o Search for the ‘medications prior to surgery’ for every patient in data set
o Difficult to extract medications just on the basis of keywords
Unstructured EMR File
o Search for the keywords ‘Doppler’ and ‘CT’ under the tab named ‘RAD’ (for radiology files)
o Manually search for the positive or negative keywords for ‘Thromboembolism’
60. SCOPE OF IMPROVEMENT
60
UPMC VTE 3.0
Analyzing the Interaction of Post-operative Medications
o Extracted individual medications and the patients on the regimen
o Further analyze the interaction of medications leading to bleed or clot condition
HAS-BLED and CHADS2 Criteria
o Multiple patients with low scores getting bled or clotted and multiple patients with high scores NOT getting bled or
clotted
o Criteria like ‘hypertension history’ and ‘stroke history’ is difficult to identify
o Explore alternate scoring systems for identifying the risk of both ‘bleed’ and ‘clot’
61. WHAT WE DID BETTER
61
VTE 1.0
VTE 2.0
VTE 3.0
61%
22%
2.34%
VTE 1.0
VTE 2.0
VTE 3.0
780%
83.7% 28.69%
CLOT OVER-IDENTIFICATION
BLEED OVER-IDENTIFICATION
UPMC VTE 3.0
AUTOMATED
SYSTEM FOR
DATA
PROCESSING
FLEXIBILE
WINDOWING
BLEED
CRITERIA
STRUCTURED
LEARNING
CLOT CRITERIA
