Invited Commentary
Reducing Missed Doses of VTE Prophylaxis
John T. Simpson, Krista L. Haines, Suresh Agarwal
JAMA Surg Published Online: October 8, 2025
doi: 10.1001/jamasurg.2025.4142
In their prospective cohort study, Haut et al1 apply a quality improvement intervention to reduce missed venous thromboembolism (VTE) chemoprophylaxis among patients hospitalized in a community hospital. Through nursing education, real-time missed dose alerts, and a patient-centered education bundle, the authors found a statistically significant reduction in missed doses of pharmacologic VTE prophylaxis (12.9% vs 9.3%; odds ratio [OR], 0.60; 95% CI, 0.55-0.66) and patient refusals (8.8% vs 5.8%; OR, 0.51; 95% CI, 0.46-0.58).1
The authors deserve praise for implementing a simple and effective academic quality improvement intervention in a community hospital setting without dedicated research funding or staff. However, many key questions remain.
Patient refusal of VTE chemoprophylaxis appears to be key to the success of their intervention; the authors note that they achieved a 49% reduction in missed doses after the implementation of the patient-centered education bundle. The bundle comprised 3 components: a nursing-led discussion, an informative paper handout, and an educational video. Patients could receive any components of the bundle. However, the study did not report how frequently individual educational components or combinations of interventions were used. Subgroup analysis could elucidate which modes of communication are most effective and further simplify future educational efforts.
Another concern is the lack of clinical outcome data, specifically VTE events, which limits a true understanding of patient benefit. The study used missed doses as a surrogate measure, relying on the assumption that a reduction in the number of missed doses directly translates to a decrease in VTE events. While this is a logical assumption that has been previously demonstrated in certain high-risk patient populations, it is less clear among all hospitalized patients.2,3 For example, Haut et al4 delivered this same intervention in an academic hospital and found no significant difference in the VTE event rate.4 A correlation between the intervention and improved VTE rates is strictly speculative. Despite little financial impact from the program, time and effort of patients and practitioners should be reflected in a clearly demonstrated improvement in outcomes. Stated otherwise, even if you can reduce missed prophylaxis doses, does the intervention truly make a difference if there is no change in VTE events?
Finally, the limited 6-month postintervention follow-up period is likely insufficient to monitor the long-term sustainability of the educational intervention. Quality improvement interventions are often subject to decay, beginning as early as several months. Maintaining meaningful change in practice patterns requires active reinforcement through continued monitoring, reeducation, cultural change, and leadership support.5
In summary, this study demonstrated that a VTE prophylaxis education bundle can be implemented outside the academic setting to reduce missed VTE chemoprophylaxis. Future research should further examine the individual components of the education bundle, patient-centered and clinically important outcomes, and overall sustainability.
