***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The American College of Chest Physicians addressed the dilemma of identifying optimal therapy for venous thromboembolism ( VTE ) prophylaxis and published their Fourth Consensus Conference on Antithrombotic Therapy in 1995 , with recommendations for prophylactic therapy . Despite these recommendations , appropriate VTE prophylactic therapy is underused . OBJECTIVES To examine routine practice s in the prevention of VTE in high-risk surgical patients and to determine the extent of adoption of grade A prophylactic therapies as recommended by the American College of Chest Physicians . METHODS Retrospective medical record review in 10 teaching or community-based hospitals located in the United States . Medical charts of 1907 patients were r and omly selected for review from the population of patients who underwent high-risk major abdominal surgery , total hip replacement , hip fracture repair , or total knee replacement between January 1 , 1996 , and February 28 , 1997 . RESULTS Of 1907 patients ,  VTE prophylaxis  was used in 89.3 % ; use was 93.7 % in each of the 3 orthopedic surgery groups and 75.2 % in the high-risk major abdominal surgery group . The percentage of patients receiving grade A therapy  was highest in the hip replacement group ( 84.3 % ) vs. the other groups ( knee replacement , 75.9 % ; hip fracture repair , 45.2 % ; abdominal surgery , 50.3 % ) . CONCLUSIONS The use of  grade A prophylaxis  was related to the type of surgery , with the highest use seen in total hip replacement and the lowest in hip fracture repair . One in 4 patients who underwent high-risk major abdominal surgeries failed to receive any form of VTE prophylaxis . Publication of consensus statements alone may be insufficient to ensure the incorporation of important new clinical information into routine practice OBJECTIVE Evaluation of the safety and potential cost savings of a computerized , laboratory-based program to manage inpatient warfarin thromboprophylaxis after major joint arthroplasty . DESIGN A consecutive-case study of adults . SETTING A tertiary care orthopedic institution . PATIENTS Patients requiring joint arthroplasty who had no recent episodes of thromboembolic disease , no mechanical heart valve , atrial fibrillation , severe liver disease or baseline international normalized ratio [ INR ] greater than 1.3 admitted over a 54-month period ( July 1994-December 1998 ) . All patients received a st and ard regimen of warfarin beginning on the evening after the operation . Four hundred and thirty r and omly selected patients managed by the program were followed up by telephone survey 3 months after discharge . Patients exhibiting erratic responses to warfarin were withdrawn from the program and managed individually thereafter . INTERVENTION Major joint arthroplasty with warfarin therapy administered through the computerized program . MAIN OUTCOME MEASURES Test results maintained within the desired therapeutic range ( INR 2.0 - 3.0 ) , clinical ly severe bleeding episodes , readmission rates , clinical ly symptomatic and venographically proven episodes of venous thrombosis or pulmonary embolism . RESULTS Over the study period 5629 patients underwent joint arthroplasty ; 5,372 patients were considered for the program ; 332 patients were ineligible and were managed individually ; 311 entered patients did not complete the program . This left 4,729 patients who completed the program . In 2932 ( 62 % ) patients test results were maintained in the desired therapeutic range . The major bleeding rate was less than 0.5 % , the readmission rate was 3.8 % , the deep venous thrombosis rate was 3.7 % and the pulmonary embolism rate was 0.2 % with no thromboembolic related deaths in the small sample cohort . CONCLUSIONS The majority of patients requiring warfarin thromboprophylaxis can be safely and effectively managed by this laboratory-based computerized program while in hospital . Significant potential cost savings in nursing time could be achieved BACKGROUND Clinical management guidelines ( CMGs ) have been developed to st and ardize physician practice s and ensure safe and cost-effective patient care . In June 1996 , evidence -based CMGs  were initiated at our urban Level I trauma center . This study compares physician compliance with two such CMGs before ( PRE ) and after ( POST ) the institution of continuous surveillance by a clinical re source manager . STUDY DESIGN For 2 months PRE re source manager surveillance hospital records were review ed retrospectively for compliance with two CMGs . POST data were collected prospect ively for 2 months by the re source manager , who alerted practitioners to deviance from CMGs to justify or document therapy alternatives . The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis . " Under " or " over " therapy described that which fell short of or exceeded guidelines . Data were analyzed by chi-square ; p < 0.05 defined statistical significance . RESULTS Compliance with the CMGs was 48 % PRE and 74 % POST ( p=0.001 ) . All noncompliant instances POST ( and none PRE ) were altered or justified . Deep venous thrombosis and ulcer " over " therapy was significantly higher PRE ( 19 % versus 2 % , p=0.003 ; 49 % versus 19 % , p=0.001 ) , result ing in $ 22,760.35 in costs . There was no difference in pulmonary embolism or gastrointestinal bleed rate ( 1 % ) PRE to POST . CONCLUSIONS The use of a clinical re source manager empowered to monitor and coordinate physician behavior improves compliance with CMGs . Further study is warranted to vali date result ant outcomes benefit , specifically cost-effectiveness and duration of the need for such a program Clinical management policies are meant to lead to the delivery of better health care . However , as we demonstrate in this review , having an oral or written venous thromboembolism prophylaxis policy does not necessarily lead to the majority of general surgical in patients receiving the appropriate prophylaxis . We discovered , through prospect i ve clinical audit , that for a clinical policy to be effective in delivering the appropriate health care , it must be repeatedly scrutinized and implemented in the correct manner . Only after several rounds of the audit cycle were we able to achieve the deliverance of venous thromboembolism prophylaxis to the majority of general surgical patients on our unit . This has wider implication s , not just for the implementation of a venous thromboembolism prophylaxis policy , but also for all clinical management policies , and illustrates the importance of clinical audit in clinical practice Two hundred admissions to a general surgical ward were audited prospect ively before and after the introduction of a thromboembolic risk score . This was based on the Thromboembolic Risk Factors ( THRIFT ) Consensus Group guidelines for thrombo-prophylaxis . The results showed an overall improvement in compliance from 65 % to 79 % . High risk patients formed 24 % of the patients studied . In this group , compliance improved significantly from 14 % to 58 % . The overall prevalence of important thromboembolic risk factors was calculated . Of the patients , 26.5 % had a Body Mass Index ( BMI ) of > 25 , and 10 % gave a past or family history of thromboembolism . Of female patients , 24 % were taking oestrogens .  We conclude that quantitative assessment of all patients for thromboembolic risk can improve the implementation of thromboprophylaxis , particularly in high risk patients OBJECTIVE With rising health care costs , methods to decrease length of hospital stay without compromising care are necessary . One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio . The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin ( LMWH ) and oral warfarin in this population . The LMWH Expedited Anticoagulation Program ( LEAP ) was created with the following goals : to decrease the number of inpatient warfarin days and to reduce overall number of hospital days . METHODS Inpatient anticoagulation was initiated with warfarin and LMWH . LEAP included early multidisciplinary collaboration to ensure third-party approval , outpatient primary care physician follow-up , and LMWH self-injection before discharge . Patients were discharged on LMWH ( discontinued by primary care provider when a therapeutic international normalized ratio was attained ) and warfarin ( continued until resolution of orthopedic injuries ) . From August 2000 to August 2001 , adult patients were included in the prospect i ve study . Primary inclusion criteria were blunt acetabular fracture , bilateral lower extremity fracture , and contralateral upper and lower extremity fractures . Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population . Anticoagulation care was similar for the study and control subjects . RESULTS There were 182 patients evaluated for LEAP inclusion . After initial evaluation , 108 patients were enrolled in LEAP ( Injury Severity Score of 13 ) . There were 69 control subjects ( Injury Severity Score of 13 ) . The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study population s , respectively ( p < 0.0001 ) . The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study ( LEAP ) population ( p < 0.002 ) . CONCLUSION LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis . These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy OBJECTIVE To measure the effect of a computerized reminder system on the rate of deep vein thrombosis ( DVT ) prophylaxis in surgical patients . DESIGN A prospect i ve trial to measure change in compliance compared to historic controls . MEASUREMENTS LDS Hospital surgeons developed local consensus as to which procedures should have DVT prophylaxis . The historic rate of prophylaxis for the procedures was measured through a data base search of patient records . A computerized reminder system was then implemented which utilized an expert knowledge base and a time drive mechanism to flag surgical cases for DVT prophylaxis . For eligible patients , a DVT reminder appeared on the operating room schedule ; surgical staff used this as a guide to apply prophylaxis . During the 3 month trial the rate of DVT prophylaxis was remeasured and compared to the pre-intervention rate . RESULTS The pre-intervention rate of DVT prophylaxis over a 3 month period was 85.2 % ( 785 of 921 eligible cases ) . For the 3 months following the introduction of the computerized reminder , compliance with DVT prophylaxis increased to 99.3 % ( 1084 of 1092 eligible cases ) . The difference between the historic controls and the study subjects was highly significant ( p < 0.001 ) . CONCLUSION A computerized reminder is an effective method of increasing the rate of DVT prophylaxis in surgical patients PURPOSE Duplex ultrasound scanning was performed to detect  deep venous thrombosis ( DVT ) after hip or knee arthroplasty and evaluate application of the postoperative thromboprophylaxis consensus . PATIENTS AND METHODS A prospect i ve multicenter study was conducted between April 1995 and April 1996 in 16 centers . Thirty angiologists included 505 patients ( 370 in private clinics and 135 in university hospitals ) . Mean patient age was 71 years . There were 288 women . Hip arthroplasty was performed in 396 patients ( 78 % ) and knee arthroplasty in 109 ( 22 % ) , under general anesthesia in 323 . The postoperative thromboprophylaxis consensus was recalled prior to study onset and DVT was detected 8 and 10 days after surgery by duplex ultrasonography . RESULTS Thromboprophylaxis was prescribed by the anesthesiologist ( 57 % ) , the surgeon ( 23 % ) or an angiologist ( 20 % ) . Anticoagulation dosage was lower than the recommended dosage in 181 patients ( 36 % ) . The prevalence of detected deep venous thrombosis was 14 % ( range 11 - 17 % ) , including 21 cases of proximal DVT ( 4.2 % ) , 33 of distal DVT ( 6.5 % ) and 17 of distal muscular DVT ( 3.4 % ) . The risk of having a DVT was 1.6-fold higher in patients over 70 years of age ( p = 0.04 ) , 2.2-fold higher in case of general anesthesia ( p = 0.03 ) and 2.1-fold higher in case of reduced mobility ( p = 0.01 ) . When heparin dosage was lower than the recommended consensus dosage , prevalence of DVT was 19 % compared with 11 % for patients who received the right dosage ( RR = 1.7 , p = 0.01 ) . CONCLUS 
    Output:
    
Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines .
In general , the use of multiple strategies was more effective than a single strategy used in isolation .
There were no studies adequately powered to demonstrate a reduction in rates of VTE .
CONCLUSIONS Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice .
A number of active strategies used together , which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis , are likely to result in the achievement of optimal outcomes