Mind the Gap: Venous Thromboembolism Prophylaxis in Patients Hospitalized with Inflammatory Bowel Disease
As you board the train in London, a sign reminds you to ‘‘Mind the Gap’’ and not stumble between the train and boarding platform. Improving the quality of medical care will take countless efforts to ‘‘Mind the Gap’’ between care that could be and care that is. Bridge enough gaps and perhaps we can cross the ‘‘Quality Chasm’’ that the Institute of Medicine’s 2001 report described [1]. In epidemiologic terms, the gap between best care and usual care is described by the terms ‘‘efficacy’’ and ‘‘effectiveness.’’ A. L. Cochrane, the British epidemiologist, first articulated this difference in his classic book entitled Effectiveness and Efficiency: Random Reflections on Health Service, the textbook that launched evidencebased medicine [2]. According to Cochrane, efficacy refers to the best care achievable when provided under ideal (controlled) conditions. Effectiveness refers to care that is provided under average or usual conditions. In this issue of Digestive Diseases and Sciences, a gap in care is highlighted for patients who are hospitalized with inflammatory bowel disease (IBD). Patients with IBD are at 3to 4-fold increased risk of both primary and recurrent venous thromboembolism (VTE) compared to people without IBD, VTE can occur at a younger age than expected and pulmonary embolism (PE) also appears at rates higher than in hospitalized patients without IBD [3–7]. VTE can occur in unusual locations including the cerebrovascular system, portal vein, mesenteric and retinal veins [3]. In 2003 there were approximately 38 million discharges from US acute care hospitals [8]. Fifty-one percent of the 15 million patients discharged from medical services were judged to be at increased risk for VTE according to criteria of the American College of Chest Physicians (ACCP) [9]. VTE contributes to over 100,000 deaths each year and is one of the Agency for Healthcare Research and Quality’s (AHRQ) key strategies for improving patient safety [10]. The following is taken from the ACCP 2012 VTE guidelines: