Automated Email Reminders May Boost IVC Filter Retrieval, Cut Complications

A system that automatically sends emails to physicians reminding them to consider removing a patient’s inferior vena cava (IVC) filter after it’s served its purpose may help cut down on complications, a new study suggests.

After implementation of such a system at a single hospital, there was an increase in retrieval rates and reductions in retrieval times, complications, and adverse outcomes, lead author Bassem Mikhael, MD (Massachusetts General Hospital, Boston), and colleagues report in a study published online October 19, 2018, ahead of print in the American Journal of Cardiology.

The system is still being used at Mass General and Mikhael told TCTMD that despite the fact that this study was not randomized—it compared periods before and after the automated reminders were put in place—“our hope is that centers would see this and then consider implementing a similar system as they strive to improve their IVC filter retrieval rates.”

IVC filters have been associated with a number of complications, prompting the US Food and Drug Administration to issue a safety communication in 2010, which was later updated in 2014. After describing reports of various problems, including device migration, filter fracture, embolization, perforation of the IVC, and difficulty removing the device, the agency—noting that events might be related to how long the filter remains implanted—recommended that physicians consider removing the filters as soon as protection against pulmonary embolism is no longer needed.

However, retrieval rates remain low in everyday practice, Mikhael said.

As a way to boost retrieval, the system set up at Mass General was designed to be fully automated, without the need for dedicated full-time staff once it was up and running. The computerized system identifies IVC filter implantations based on billing codes and, after 30 days, sends the implanting physician an interactive email asking about whether the filter has been retrieved. There are no further emails if the physician indicates that the filter has been removed. If the filter has not be extracted, the physician provides information about whether there has been an unsuccessful retrieval attempt or gives a reason for why the filter will not be retrieved. Lack of response to the reminder email triggers weekly follow-up emails until the physician responds.

Before and After

To evaluate the potential impact of the system, the investigators evaluated 715 filter insertions before implementation and 355 after.

Retrieval rate was higher in the group that received email reminders (49.8% vs 31.2%; P =0 .0001), with a difference remaining after excluding patients who died within 90 days or developed a permanent indication for a filter. The median time to retrieval was shorter as well (112 vs 146 days; P = 0.02).

The reminder system also was associated with lower rates of indwelling complications (9.4% vs 16.1%; P = 0.005) and a composite of adverse outcomes, including IVC filter thrombosis, deep vein thrombosis, pulmonary embolism, and death (23.9% vs 41.5%; P = 0.0001).

“We would hypothesize that the most likely mechanism for the association with reduction in indwelling complications seen in our study is the reduction in dwell times as a result of earlier retrieval,” the authors say. “Other studies have also found that complications occur more frequently as dwell time increases.”

Mikhael said the advantage of this system over other initiatives aimed at improving retrieval rates is that it is fully automated; prior efforts have relied on dedicated personnel and have been labor intensive.

“In an increasingly cost-constricted healthcare environment, the long-term sustainability of such resource-intensive initiatives is unclear,” Mikhael et al write. “To our knowledge, our study of a computerized email-only reminder system is unique in demonstrating an association with higher rates of filter retrieval and lower complications, in a minimally resource-intensive and automated fashion.”

Moreover, the computerized system can provide “insight into physician decision-making regarding IVC filter retrieval,” they say, pointing out that “such data offer the potential to provide an additional tool for quality improvement and monitoring and eliminate the need for manual chart review.”