Economic burden of venous thromboembolism in hospitalized patients

Venous Thromboembolism in Cancer: An Update of Treatment and Prevention in the Era of Newer Anticoagulants

Cancer patients are at major risk of developing venous thromboembolism (VTE), resulting in increased morbidity and economic burden. While a number of theories try to explain its pathophysiology, its risk stratification can be broadly done in cancer-related, treatment–related, and patient-related factors. Studies report the prophylactic use of thrombolytic agents to be safe and effective in decreasing VTE-related mortality/morbidity especially in postoperative cancer patients. Recent data also suggest the prophylactic use of low molecular weight Heparins (LMWHs) and Warfarin to be effective in reducing VTEs related to long-term central venous catheter use. In a double-blind, multicenter trial, a new ultra-LMWH Semuloparin has shown to be efficacious in preventing chemotherapy-associated VTE’s along with other drugs, such as Certoparin and Nadoparin. LMWHs are reported to be very useful in preventing recurrent VTEs in advanced cancers and should be preferred over full dose Warfarin. However, their long-term safety beyond 6 months has not been established yet. Furthermore, this paper discusses the safety and efficacy of different drugs used in the treatment and prevention of recurrent VTEs, including Bemiparin, Semuloparin, oral direct thrombin inhibitors, parenteral and direct oral factor Xa inhibitors.

Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians

Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.

Surgical operative time increases the risk of deep venous thrombosis and pulmonary embolism in robotic prostatectomy

Background and Objectives:

To evaluate the effect of operative time on the risk of symptomatic venous thromboembolic events (VTEs) in patients undergoing robot-assisted radical prostatectomy (RARP).

Methods:

We reviewed the records of all patients at our institution who underwent RARP by a single surgeon from January 2007 until April 2011. Clinical and pathologic information and VTE incidence were recorded for each patient and analyzed by use of logistic regression to evaluate for association with VTE risk. All patients had mechanical prophylaxis, and beginning in February 2008, a single dose of unfractionated heparin, 5000 U, was administered before surgery.

Results:

A total of 549 consecutive patients were identified, with a median follow-up period of 8 months. During the initial 30 days postoperatively, 10 patients (1.8%) had a VTE (deep venous thrombosis in 7 and pulmonary embolism in 3). The median operative time was 177 minutes (range, 121–360 minutes). An increase in operative time of 30 or 60 minutes was associated with 1.6 and 2.8 times increased VTE risks. A 5-point increase in body mass index and need for blood transfusion were also associated with increased risk of VTEs (odds ratios of 2.0 and 11.8, respectively). Heparin prophylaxis was not associated with a significant VTE risk reduction but also was not associated with a significant increase in estimated blood loss (P = .23) or transfusion rate (P = .37).

Conclusion:

A prolonged operative time increases the risk of symptomatic VTEs after RARP. Future studies are needed to evaluate the best VTE prophylactic approach in patients at risk.

Validation of the International Medical Prevention Registry on Venous Thromboembolism Bleeding Risk Score

BACKGROUND

Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS.

METHODS

We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events.

RESULTS

From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major (P = .02) and clinically important (major plus clinically relevant nonmajor) (P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07).

CONCLUSIONS

The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.

Comparison of the Novel Oral Anticoagulants Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in the Initial and Long-Term Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis

Background

Anticoagulation with low molecular weight heparin and vitamin K antagonists is the current standard of care (SOC) for venous thromboembolism (VTE) treatment and prevention. Although novel oral anti-coagulants (NOACs) have been compared with SOC in this indication, no head-to-head randomised controlled trials (RCTs) have directly compared NOACs. A systematic review and network meta-analysis (NMA) were conducted to compare the efficacy and safety of NOACs for the initial and long-term treatment of VTE.

Methods

Electronic databases (accessed July 2014) were systematically searched to identify RCTs evaluating apixaban, dabigatran, edoxaban, and rivaroxaban versus SOC. Eligible patients included adults with an objectively confirmed deep vein thrombosis (DVT), pulmonary embolism (PE) or both. A fixed-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as relative risks (RR) and 95% credible intervals (Crl).

Results

Six Phase III RCTs met criteria for inclusion: apixaban (one RCT; n = 5,395); rivaroxaban (two RCTs; n = 3,423/4,832); dabigatran (two RCTs; n = 2,539/2,568); edoxaban (one RCT; n = 8,240). There were no statistically significant differences between the NOACs with regard to the risk of ‘VTE and VTE-related death. Apixaban treatment was associated with the most favourable safety profile of the NOACs, showing a statistically significantly reduced risk of ‘major or clinically relevant non-major (CRNM) bleed’ compared with rivaroxaban (0.47 [0.36, 0.61]), dabigatran (0.69 [0.51, 0.94]), and edoxaban (0.54 [0.41, 0.69]). Dabigatran was also associated with a significantly lower risk of ‘major or CRNM bleed’ compared with rivaroxaban (0.68 [0.53, 0.87]) and edoxaban (0.77 [0.60, 0.99]).

Conclusions

Indirect comparisons showed statistically similar reductions in the risk of ‘VTE or VTE-related death for all NOACs. In contrast, reductions in ‘major or CRNM bleed’ for initial/long-term treatment were significantly better with apixaban compared with all other NOACs, and with dabigatran compared with rivaroxaban and edoxaban. Results from the current analysis indicate that the NOACs offer clinical benefit over conventional therapy while highlighting relative differences in their bleeding profile.

Pharmacomechanical thrombolysis with a rotator thrombolysis device in iliofemoral deep venous thrombosis

OBJECTIVE

Deep venous thrombosis (DVT) is a life-threatening and morbid pathology. This study aimed to investigate the efficacy of an early thrombolysis procedure using a rotator thrombolysis device.

METHODS

Sixty-seven patients with acute proximal DVT were enrolled in the study. Patients' data were recorded retrospectively. Initially, an infrarenal retrievable vena cava filter was placed through the femoral vein. Then, a rotator thrombolysis device and a thrombolytic agent injection were applied to the occluded segments of the deep veins by puncturing the popliteal vein.

RESULTS

The identified reasons were trauma (43.3%), pregnancy (20.9%), undiagnosed (11.9%), major surgical operation (10.5%), immobilization (7.5%), and malignancy (5.9%). Immediate total recanalization was conducted in all patients, and the leg diameters returned to normal ranges in the early postoperative period. Hospital mortality or severe complications were not detected.

CONCLUSION

New thrombolytic devices seem to reduce in-hospital mortality risks and may potentially decrease post-thrombotic morbidity.

Apixaban for the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism: an evidence-based review

Venous thromboembolism (VTE) results in significant morbidity and mortality. The prevention and treatment of VTE is managed with anticoagulant therapy, historically parenteral anticoagulants such as unfractionated heparin, low molecular weight heparin, and fondaparinux, and oral vitamin K antagonists such as warfarin. In the last few years, several target-specific oral anticoagulants have been developed, including the direct thrombin inhibitor dabigatran and anti-Xa inhibitors rivaroxaban, apixaban, and edoxaban. The target-specific oral anticoagulants have proven to be noninferior to vitamin K antagonists and heparins in the prevention and treatment of VTE. This review will focus on the pharmacology, clinical trial data, and laboratory assessment of apixaban. Moreover, perioperative management, use in special populations, and management of bleeding complications in patients taking apixaban for the prevention and treatment of VTE will also be discussed.

The humanistic and economic burden of venous thromboembolism in cancer patients: a systematic review

The objective of this study was to present evidence on the epidemiology, health outcomes and economic burden of cancer-related venous thromboembolism (VTE). Medline, Cochrane Central Register of Controlled Trials, Econlit, Science Direct, JSTOR, Oxford Journals and Cambridge Journals were searched. The systematic literature search was limited to manuscripts published from January 2000 to December 2012. On the basis of the literature, cancer patients experience between two-fold and 20-fold higher risk of developing VTE than noncancer patients. They are more likely to experience a VTE event during the first 3-6 months after cancer diagnosis. In addition, an increased risk of VTE in patients with distant metastases and certain types of cancer (i.e. pancreatic or lung) was revealed. VTE was found to be a leading cause of mortality in cancer patients. The annual average total cost for cancer patients with VTE was found to be almost 50% higher than that of cancer patients without VTE. Inpatient care costs accounted for more than 60% of total cost. The existing evidence assessed in the present review demonstrated the significant health and economic consequences of cancer-related VTE, which make a strong case for the importance of its proper and efficient prevention and management.

Cost-effectiveness analysis of treatment of venous thromboembolism with rivaroxaban compared with combined low molecular weight heparin/vitamin K antagonist

Background

Venous thromboembolism (VTE) is a burden on healthcare systems. Standard treatment involves parenteral anticoagulation overlapping with a vitamin K antagonist, an approach that is effective but associated with limitations including the need for frequent coagulation monitoring. The direct oral anticoagulant rivaroxaban is similarly effective to standard therapy as a single-drug treatment for VTE and does not require routine coagulation monitoring. The objective of this economic evaluation was to estimate the cost-effectiveness of rivaroxaban compared with standard VTE treatment from a UK perspective.

Methods

A Markov model was constructed using data and probabilities derived from the EINSTEIN DVT and EINSTEIN PE studies of rivaroxaban and other published sources. Health outcomes included VTE rates, bleeding events avoided, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).

Results

There was greater discounted quality-adjusted life expectancy with rivaroxaban than with standard therapy, irrespective of indication and treatment duration. Rivaroxaban was associated with per-patient cost savings for each treatment duration modelled (3, 6 and 12 months), and these were greatest with shorter durations. Rivaroxaban was found to be dominant (cheaper and more effective) and, therefore, cost-effective, in both patients with deep vein thrombosis and pulmonary embolism in all three treatment duration groups, and was also cost-effective in patients requiring lifelong anticoagulation (ICERs: £8677 per QALY and £7072 per QALY in patients with index deep vein thrombosis and pulmonary embolism, respectively). The cost-effectiveness of rivaroxaban was largely insensitive to variations in one-way sensitivity analysis. Probabilistic sensitivity analysis demonstrated that at a threshold of £20,000 per QALY, rivaroxaban had a consistent probability of being cost-effective, compared with LMWH/VKA treatment, of around 80% regardless of index VTE or duration of anticoagulation therapy (3, 6, 12 months or lifelong).

Conclusions

This analysis suggests that rivaroxaban represents a cost-effective choice for acute treatment of deep vein thrombosis and pulmonary embolism and secondary prevention of VTE in the UK, compared with LMWH/VKA treatment, regardless of the required treatment duration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12959-015-0051-3) contains supplementary material, which is available to authorized users.

Red meat, processed meat and the risk of venous thromboembolism: friend or foe?

Venous thromboembolism (VTE) is a highly prevalent condition worldwide, which can be triggered by a combination of inherited and acquired risk factors, including diet. Several lines of evidence suggest that consumption of red and processed meat is associated with a significant risk of colorectal cancer, cardiovascular disease and diabetes. Therefore, an electronic search was conducted to identify clinical studies investigating the potential association between the risk of venous thrombosis and consumption of red or processed meat. Seven articles were finally included in this review, 6 prospective studies and 1 case-control investigation. Taken together, the evidence of the current scientific literature suggests that whether or not a pathophysiological link may exist between red or processed meat consumption and venous thrombosis, the association is definitely weak, since it was found to be non-statistically significant in four prospective cohort studies, marginally significant in one prospective cohort study and highly significant in the remaining prospective cohort study. In the single case-control study, the risk was also found to be non-statistically significant. Although further studies will be needed to definitely establish the existence of a thrombotic risk associated with different subtypes of red or processed meat, it seems premature to conclude that a reduced consumption of red and processed meat lowers the risk of VTE.

Cost-effective prophylaxis against venous thromboembolism after total joint arthroplasty: warfarin versus aspirin

Although recent guidelines suggest aspirin for venous thromboembolism (VTE) prophylaxis in low risk patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA), there are no cost-effectiveness studies comparing aspirin and warfarin. In a Markov cohort cost-effectiveness analysis, we found that aspirin cost less and saved more quality-adjusted life-years (QALYs) than warfarin in all age groups. Cost per QALY gained by aspirin was $24,506.20 at age of 55 and $47,148.10 at the age of 85 following THA and $15,117.20 and $24,458.10 after TKA, which were greater than warfarin. In patients undergoing THA/TKA without prior VTE, aspirin is more cost-effective prophylactic agent than warfarin. Warfarin might be a better prophylaxis in TKA patients with high probability of VTE and very low probability of bleeding.

Multilocus genetic risk scores for venous thromboembolism risk assessment

BACKGROUND

Genetics plays an important role in venous thromboembolism (VTE). Factor V Leiden (FVL or rs6025) and prothrombin gene G20210A (PT or rs1799963) are the genetic variants currently tested for VTE risk assessment. We hypothesized that primary VTE risk assessment can be improved by using genetic risk scores with more genetic markers than just FVL-rs6025 and prothrombin gene PT-rs1799963. To this end, we have designed a new genetic risk score called Thrombo inCode (TiC).

METHODS AND RESULTS

TiC was evaluated in terms of discrimination (Δ of the area under the receiver operating characteristic curve) and reclassification (integrated discrimination improvement and net reclassification improvement). This evaluation was performed using 2 age- and sex-matched case-control populations: SANTPAU (248 cases, 249 controls) and the Marseille Thrombosis Association study (MARTHA; 477 cases, 477 controls). TiC was compared with other literature-based genetic risk scores. TiC including F5 rs6025/rs118203906/rs118203905, F2 rs1799963, F12 rs1801020, F13 rs5985, SERPINC1 rs121909548, and SERPINA10 rs2232698 plus the A1 blood group (rs8176719, rs7853989, rs8176743, rs8176750) improved the area under the curve compared with a model based only on F5-rs6025 and F2-rs1799963 in SANTPAU (0.677 versus 0.575, P<0.001) and MARTHA (0.605 versus 0.576, P=0.008). TiC showed good integrated discrimination improvement of 5.49 (P<0.001) for SANTPAU and 0.96 (P=0.045) for MARTHA. Among the genetic risk scores evaluated, the proportion of VTE risk variance explained by TiC was the highest.

CONCLUSIONS

We conclude that TiC greatly improves prediction of VTE risk compared with other genetic risk scores. TiC should improve prevention, diagnosis, and treatment of VTE.

A novel method of adverse event detection can accurately identify venous thromboembolisms (VTEs) from narrative electronic health record data

BACKGROUND

Venous thromboembolisms (VTEs), which include deep vein thrombosis (DVT) and pulmonary embolism (PE), are associated with significant mortality, morbidity, and cost in hospitalized patients. To evaluate the success of preventive measures, accurate and efficient methods for monitoring VTE rates are needed. Therefore, we sought to determine the accuracy of statistical natural language processing (NLP) for identifying DVT and PE from electronic health record data.

METHODS

We randomly sampled 2000 narrative radiology reports from patients with a suspected DVT/PE in Montreal (Canada) between 2008 and 2012. We manually identified DVT/PE within each report, which served as our reference standard. Using a bag-of-words approach, we trained 10 alternative support vector machine (SVM) models predicting DVT, and 10 predicting PE. SVM training and testing was performed with nested 10-fold cross-validation, and the average accuracy of each model was measured and compared.

RESULTS

On manual review, 324 (16.2%) reports were DVT-positive and 154 (7.7%) were PE-positive. The best DVT model achieved an average sensitivity of 0.80 (95% CI 0.76 to 0.85), specificity of 0.98 (98% CI 0.97 to 0.99), positive predictive value (PPV) of 0.89 (95% CI 0.85 to 0.93), and an area under the curve (AUC) of 0.98 (95% CI 0.97 to 0.99). The best PE model achieved sensitivity of 0.79 (95% CI 0.73 to 0.85), specificity of 0.99 (95% CI 0.98 to 0.99), PPV of 0.84 (95% CI 0.75 to 0.92), and AUC of 0.99 (95% CI 0.98 to 1.00).

CONCLUSIONS

Statistical NLP can accurately identify VTE from narrative radiology reports.

Endovascular Treatment of Deep Vein Thrombosis

Venous thromboembolism (VTE) is associated with substantial morbidity and mortality. Conventional treatment with anticoagulation therapy may undertreat the condition. Patients with VTE are at risk for recurrence with increasing time passage. Endovascular approaches exist for treating VTE, including deep vein thrombosis, but it is unclear which patients are appropriate candidates for endovascular versus medical approaches. Many new endovascular technologies are in development, and new oral anticoagulants are also on the market. Clinicians must be mindful of these new products and use them appropriately to better manage VTE.

The use of oral anticoagulants for the treatment of venous thromboembolic events in an ED

Venous thromboembolism (VTE) is a disease spectrum that ranges from deep vein thrombosis (DVT) to pulmonary embolism (PE). Rapid diagnosis and treatment of VTE by emergency care providers are critical for decreasing patient mortality, morbidity, and the incidence of recurrent events. Recent American College of Chest Physicians guidelines recommend initial treatment with unfractionated heparin, low-molecular weight heparin, or fondaparinux overlapped with warfarin for a minimum of 5 days for the treatment of VTE in most cases. Warfarin monotherapy is thereafter continued for 3, 6, or 12 months. These guidelines were published before the approval of target-specific oral anticoagulants (TSOACs), and they have yet to be updated to reflect these new treatment options. For some patients, TSOACs, which act by directly inhibiting factor IIa or factor Xa, may provide safer, more convenient alternatives to warfarin. Their advantages include ease of use, reduced monitoring requirements, and lower bleeding risk than traditional therapy. Additionally, clinical trials have established noninferiority of TSOACs to warfarin for the prevention of recurrent VTE. These trials have demonstrated that TSOACs exhibit similar or lower bleeding rates, particularly intracranial bleeding rates compared with warfarin. Anticoagulation therapy with TSOACs may allow early discharge or outpatient management options for low-risk patients with DVT and PE. This review addresses the importance of early diagnosis and treatment of VTE, outcomes of VTE risk assessment, key efficacy and safety data from phase 3 clinical trials for the various TSOACs for the treatment of DVT and PE, and the corresponding considerations for clinical practice.

Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis

We performed a systematic review of published studies that evaluated the potential risk factors and outcomes of venous thromboembolism (VTE) in hospitalized children. A total of 761 VTE patients from six published studies were identified. The mean prevalence of VTE in children admitted to the hospital was 9.7/10 000 admissions. The presence of a central venous catheter was found to be the single most important predisposing cause of VTE, with a pooled percentage of 29%. Infection was the second most common cause of the disease (20%). Pulmonary embolism occurred in 15% (113/745) of the patients. The overall recurrence rate of VTE was 16% (74/464) and the mortality rate was 8% (59/704). Although uncommon, orthopedic surgeons need to be aware of the unique risk factors for VTE among pediatric inpatients. Hospitalized children and adolescents with known risk factors for VTE should be considered candidates for VTE screening or prophylaxis.

Current practice of venous thromboembolism prevention in acute trusts: a qualitative study

OBJECTIVE

To explore the current practice of venous thromboembolism (VTE) prevention in acute trusts.

DESIGN

A qualitative research design was used to explore the perceived current practice of thromboprophylaxis, and knowledge and experience of VTE prevention. Data were collected via interviews with personnel from acute trusts and other relevant organisations and charities. Constant comparison was used to generate themes grounded in the data.

SETTING

The UK.

PARTICIPANTS

17 participants, sampled due to their expertise and knowledge in the field of VTE, were interviewed for the study.

RESULTS

No one felt directly responsible for VTE risk assessment and treatment in acute trusts. There were concerns whether any action takes place based on the risk assessment. Low levels of VTE knowledge existed throughout the system.

CONCLUSIONS

Our study highlights the importance of continuous training to prevent VTE risk assessment being considered a tick box exercise and for clinicians to understand the significance of the procedure to ensure that VTE preventative measures are administered. It is essential that acute trust staff acknowledge that VTE prevention is the responsibility of everyone involved in a patient's care. Concerns remain around prophylaxis treatment, administration and contraindications.

Cost of venous thromboembolism in hospitalized medically ill patients

PURPOSE

The results of a study to estimate the economic costs of venous thromboembolism (VTE) in hospitalized nonsurgical patients during initial admissions and subsequent to hospital discharge are presented.

METHODS

Using a database linking admission records from more than 150 U.S. hospitals to health insurance claims, 49,948 patients 40 years of age or older who were hospitalized at least once during a 6-year period for diagnoses other than VTE or traumatic injury and who met other inclusion criteria were identified. Costs were tallied from the index admission to postdischarge day 180 for patients with and patients without evidence of VTE. Ordinary least-squares regression was used to estimate the independent relationship between VTE and total health care costs, controlling for differences in patient characteristics.

RESULTS

Two hundred forty-two patients (0.5%) had VTE during the index admission, 317 (0.6%) had VTE after the index admission discharge; in total, 559 (1.1%) had VTE through postdischarge day 180. Among the 242 patients with VTE during their index admission, the adjusted mean total health care costs over 180 days were $17,848 higher than among those without VTE ($47,416 versus $29,568, p < 0.001); for the 317 patients with postdischarge VTE, the adjusted mean total 180-day costs were $51,863 higher than for those without postdischarge VTE ($74,136 versus $22,273, p < 0.001).

CONCLUSION

Among medically ill patients admitted to the hospital, health care costs were significantly higher among those who developed VTE during hospitalization or after discharge compared with those who did not develop VTE.

Prevention of venous thromboembolism in hospitalized patients: analysis of reduced cost and improved clinical outcomes

The impact of implementing a guideline on venous thromboembolism (VTE) prophylaxis was evaluated in a metropolitan private hospital with a before- and after-intervention study. This subsequent study aimed to identify if improved prophylaxis rates translated into cost savings and improved clinical outcomes. A conceptual decision-tree analytical model incorporating local treatment algorithms and clinical trial data was used to compare prophylaxis costs and clinical outcomes before and after the guideline implementation. The study analyzed data from 21,942 medical and surgical patients admitted to a 250-bed acute-care private hospital in Sydney, Australia. The modeled simulation estimated the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as adverse events such as heparin-induced thrombocytopenia (HIT), post-thrombotic syndrome (PTS), major bleeding, and mortality. The costs of prophylaxis therapy and treating adverse events were also calculated. The improvement in prophylaxis rates following the implementation of the guideline was estimated to result in 13 fewer deaths, 84 fewer symptomatic DVTs, 19 fewer symptomatic PEs, and 512 fewer hospital-bed days. Improved adherence to evidence-based prophylaxis regimens was associated with overall cost savings of $245,439 over 12 months. We conclude that improved adherence to evidence-based guidelines for VTE prophylaxis is achievable and is likely to result in fewer deaths, fewer VTE events, and a significant overall cost saving.

Primary venous thromboembolism prophylaxis in patients with solid tumors: a meta-analysis

Venous thromboembolism (VTE) is a leading cause of death among outpatient chemotherapy patients. However the VTE preventive measures for outpatients are not widely advocated. We did a meta-analysis to evaluate the outpatient VTE prevention's effectiveness and safety. We searched electronic databases until the end of December 2012 and reviewed the abstracts and manuscripts following the PRISMA guidelines. Occurrence of first VTE event was the efficacy outcome. The safety end point was major bleeding. We calculated Q statistic and a homogeneity formal test. The odds ratio (OR) estimates were pooled by using the Mantel-Haenszel fixed-effects method in the absence of heterogeneity. Data were analyzed using the R META package). We identified 1,485 articles and reviewed 37 articles based on initial screening. The number of patients included in 11 selected trials was 7,805. The odds of VTE was lower in the prophylaxis group (OR 0.56; 95% CI 0.45-0.71) and improved when heparin-based prevention was analyzed (OR 0.53; 95% CI 0.41-0.70). We found strong prevention among patients with lung cancer (OR 0.46; 95% CI 0.29-0.74) and pancreatic cancer (OR 0.33; 95% CI 0.16-0.67). Major bleeding events were frequent in the intervention group (OR 1.65; 95% CI 1.12-2.44). Thromboprophylaxis reduced VTE episodes. The VTE events were reduced by 47% in heparin-based prophylaxis trials compared to placebo. The patients receiving heparin-based prophylaxis had a 60% increase in bleeding events. Improving risk stratification tools to personalize prevention strategies may enhance the VTE prevention applicability in cancer patients.

Economic Implications of Inadequate Treatment of Venous Thromboembolism and Potential Solutions

Venous thromboembolism (VTE) is a common and serious medical complication among medical and surgical patients, both in the hospital and postdischarge. Patients with venous stasis or vascular damage or those with underlying hypercoagulable disorders, including cancer, are at risk of developing VTE. The clinical consequences of inadequate treatment of VTE can result in significant patient morbidity and mortality. The direct health care costs and indirect societal costs related to VTE and its complications are high. Traditional anticoagulants can reduce recurrent VTE but they present costly management challenges. Oral anticoagulants currently in development offer simpler management compared with the established agents, potentially resulting in improved adherence with VTE treatment regimens and better outcomes. Reductions in recurrent VTE and its associated complications could translate into reduced direct and indirect costs.

Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study

BACKGROUND

Despite the availability of evidence-based guidelines on venous thromboembolism (VTE) prevention clinical audit and research reveals that hospitalised medical patients frequently receive suboptimal prophylaxis. The aim of this study was to evaluate the acceptability, utility and clinical impact of an educational outreach visit (EOV) on the provision of VTE prophylaxis to hospitalised medical patients in a 270 bed acute care private hospital in metropolitan Australia.

METHODS

The study used an uncontrolled before-and-after design with accompanying process evaluation. The acceptability of the intervention to participants was measured with a post intervention survey; descriptive data on resource use was collected as a measure of utility; and clinical impact (prophylaxis rate) was assessed by pre and post intervention clinical audits. Doctors who admit >40 medical patients each year were targeted to receive the intervention which consisted of a one-to-one educational visit on VTE prevention from a trained peer facilitator. The EOV protocol was designed by a multidisciplinary group of healthcare professionals using social marketing theory.

RESULTS

Nineteen (73%) of 26 eligible participants received an EOV. The majority (n = 16, 85%) felt the EOV was effective or extremely effective at increasing their knowledge about VTE prophylaxis and 15 (78%) gave a verbal commitment to provide evidence-based prophylaxis. The average length of each visit was 15 minutes (IQ range 15 to 20) and the average time spent arranging and conducting each visit was 92 minutes (IQ range 78 to 129). There was a significant improvement in the proportion of medical patients receiving appropriate pharmacological VTE prophylaxis following the intervention (54% to 70%, 16% improvement, 95% CI 5 to 26, p = 0.004).

CONCLUSIONS

EOV is effective at improving doctors' provision of pharmacological VTE prophylaxis to hospitalised medical patients. It was also found to be an acceptable implementation strategy by the majority of participants; however, it was resource intensive requiring on average 92 minutes per visit.

New oral therapies for the prevention and treatment of venous thromboembolism

PURPOSE

Data comparing traditional and novel anticoagulants are reviewed, and the potential use of new oral agents for the prevention and treatment of venous thromboembolism (VTE) is assessed.

SUMMARY

Practical challenges in using traditional anticoagulants are well established and have led to the search for new oral agents. Apixaban, rivaroxaban, and dabigatran etexilate are new oral anticoagulants that may offer simpler, more effective, and safer treatment and prevention of VTE, which may increase adherence to such therapy, improve outcomes, and decrease overall health care costs. Their immediate onset of anticoagulant effect, ease of oral administration, and lack of needed regular anticoagulation monitoring are of interest in the medical and pharmacy communities. However, in the treatment and prevention of VTE, more data will be needed to determine their ultimate place in therapy. This review is intended to provide pharmacists with an objective overview of practical considerations that can help them understand the clinical data to facilitate their selection of anticoagulants.

CONCLUSION

Apixaban, rivaroxaban, and dabigatran etexilate are new oral agents for the prevention and treatment of VTE.

Pharmacoeconomic implications of thromboprophylaxis with new oral anticoagulants after total hip or knee replacement in the USA

INTRODUCTION

Adequate thromboprophylaxis after total hip or knee replacement (THR or TKR) is essential to reduce the incidence of venous thromboembolism (VTE) and its associated complications. Although effective, traditional anticoagulants are associated with a considerable economic burden, particularly when used outside the hospital setting. This article explores whether newer oral anticoagulants can reduce costs of VTE prophylaxis and therapy.

AREAS COVERED

Cost associated with vitamin K antagonists; indirect costs associated with complicated or inconvenient anticoagulation regimens, non-adherence and associated complications; potential of the newer oral anticoagulants, including direct thrombin inhibitors and direct factor Xa inhibitors, to produce indirect cost savings after THR or TKR through a potential reduction in VTE rates and administration and monitoring costs.

EXPERT OPINION

The use of new anticoagulants for VTE prophylaxis after THR or TKR can result in direct and indirect cost savings through improved efficacy by reducing VTE rates and decreased drug administration and monitoring costs compared with traditional anticoagulants. Future research will need to focus on cost analyses driven by clinical outcomes measured on the performance of these agents in actual clinical practice.

Prevention and treatment of venous thromboembolism with new oral anticoagulants: a practical update for clinicians

Traditional anticoagulants, such as warfarin and enoxaparin, have several limitations, including parenteral administration, need for laboratory monitoring, and ongoing dose adjustment, which may limit optimal patient care. Newer oral anticoagulants, such as direct thrombin inhibitors (e.g., dabigatran etexilate) and direct factor Xa inhibitors (e.g., rivaroxaban, apixaban, and edoxaban), have been developed to overcome these drawbacks, and thereby improve patient care. Several of these agents have been approved for use in the prevention and treatment of venous and/or systemic thromboembolism. The objective of this paper is to provide an overview of the available clinical trial data for these new oral anticoagulants in the prevention and treatment of venous thromboembolism and a practical update for clinicians.

Using a venous thromboembolism checklist significantly improves VTE prevention: a junior doctor led intervention

AIMS

Given that venous thromboembolic disease is a significant cause of morbidity and mortality, the aim of this study was to increase the rate of VTE risk assessment performed by junior doctors in the acute setting. We also wanted to increase the rates of prescription of thromboembolic preventative measures in those patients whom the assessment identified as being high risk.

METHODS

A survey of all patients admitted to three medical wards over a 3-week period was performed to determine whether VTE risk assessment had been performed, and whether prescription of prophylactic measures had been carried out where appropriate. A prompt sheet was subsequently attached to the drug card, and the survey repeated to assess impact on risk assessment and prescription rates.

RESULTS

Use of the prompt sheet significantly increased the percentage of patients being appropriately prescribed VTE prophylaxis. CONCLUSIONS/MESSAGE FOR THE CLINIC: Most physicans are aware of the risk of VTE to inpatients, but because of human factors throughout the daily ward activities, VTE assessment can be missed. A simple intervention such as a VTE assessment prompt sheet on the front of the drug card can significantly improve VTE assessment and therefore patient safety.

Hospital costs of acute pulmonary embolism

OBJECTIVE

Pulmonary embolism places a heavy economic burden on health care systems, but the components of hospital cost have not been elucidated. We evaluated hospitalized patients with the primary diagnosis of pulmonary embolism. Our goal was to determine the total and component costs associated with their hospital care.

METHODS

We included patients hospitalized at Brigham and Women's Hospital from September 2003 to May 2010. Patient demographics, characteristics, comorbidities, interventions, and treatments were obtained from the electronic medical record. Costs were obtained using the hospital's accounting software and categorized into the areas providing direct patient supplies or care.

RESULTS

We identified 991 hospitalized patients with acute pulmonary embolism. In-hospital mortality was 4.2%, and 90-day mortality after hospital discharge was 13.8%. The median length of hospital stay was 3 days, and the mean length of hospital stay was 4 days. The mean total hospitalization cost per patient was $8764. Nursing costs, which included room and board, were $5102. Pharmacy ($966) and radiology ($963) costs were similar. Pharmacy costs ($966) were dominated by the use of low-molecular-weight heparin ($232). Radiology costs ($963) were dominated by the use of diagnostic imaging examinations ($672). During the observation period, an average of 160 patients with pulmonary embolism were admitted each year, requiring an annual hospital expense ranging from $884,814 to $1,866,489.

CONCLUSIONS

Pulmonary embolism has a high case fatality rate and remains an expensive illness to diagnose and treat. Nursing costs comprise the largest component of costs.

Real-world economic burden of venous thromboembolism and antithrombotic prophylaxis in medical inpatients

INTRODUCTION

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in medical patients, and the economic burden of this disease is plausibly relevant as well. However, few data from real-world observations are available on this topic. Aim of our study was to assess the costs of VTE management and antithrombotic prophylaxis in patients hospitalized in Internal Medicine (IM) departments.

MATERIALS AND METHODS

The in-hospital paths of 160 patients with VTE (VTE group) and 160 patients receiving prophylaxis and without VTE (NO-VTE group) were retrospectively evaluated within 26IM units in Italy. The economic analysis was undertaken by applying a process analysis, the initial phase of the more comprehensive Activity Based Costing technique. Accordingly to this approach, only information closely linked to VTE or its prevention was registered.

RESULTS

The total median costs for VTE management were around four-times higher than those for prophylaxis (€ 1,348.68 vs € 373.03). Human resources were the most important cost-driver (55.5% and 65.7% in the VTE and NO-VTE groups), followed by instrumental (24.6% in VTE and 15.5% in NO-VTE) and haematologic tests (12.6% in VTE patients and 13.3% in controls). In the NO-VTE group the direct costs for prophylaxis accounted for 4.5% of total.

CONCLUSIONS

The real-world data of this study confirm the economic burden of in-hospital treatment of VTE, and the relatively low costs of thromboprophylaxis. A greater adherence to evidence-based protocols for VTE prevention could probably reduce the current financial burden of VTE on healthcare systems.

Prevalence and economic burden of pulmonary embolism in Germany

The prevalence of pulmonary embolism (PE), PE mortality and treatment-associated costs for the years 2000 to 2006 were analysed using a statutory health insurance sample of AOK Hesse/KV Hesse, which contained information for an 18.75% random sample of 1.9 million persons insured with the AOK Hesse. Within the sample a PE diagnosis was accepted as valid if it was documented as the main discharge diagnosis or as an additional hospital diagnosis during hospitalization and if at least one of the following criteria was met: prescription of oral anticoagulants or heparins, PE documented for at least two quarterly periods or documented in only one quarter for patients who died within 28 days after hospital discharge. The economic burden from the perspective of the insurance fund was assessed by an analysis of resource consumption (direct costs) and by a matched pair analysis with controls without PE to estimate excess costs. A 99% winsorization of each cost category was performed to control for extreme outlying values. The prevalence of PE as the main discharge diagnosis and an additional hospital diagnosis varied from 55.3 to 71.7 per 100,000 insurants in the years 2000 to 2006. Insurants aged 80 years and more had a prevalence of 406.9 per 100,000 (year 2006). From 2001 to 2003 the in-hospital mortality rate ranged from 20.4% to 24.9% and decreased to 14% in 2006. A total of 85% of all patients with PE who survived the first year had at least one prescription of vitamin K antagonists. For patients who survived the first year, treatment costs exceeded € 20,000, with an estimation of additional costs of € 5816 for men and € 8962 for women in the matched-pair analysis. Owing to high in-hospital costs, the overall cost of treatment was highest for patients younger than 60 years. In conclusion, the prevalence rate of PE in Germany is comparable to international data. Treatment costs within the first year after hospital discharge are high, and there is a need to clarify the settings associated with PE in Germany with its high rate of prophylaxis.

Long-term benefits of preventing venous thromboembolic events

BACKGROUND

Venous thromboembolism (VTE) and its long-term secondary complications are major health problems associated with high rates of morbidity and mortality and considerable costs for healthcare systems. Many patients receive suboptimal therapy, despite the availability of established and effective agents (including low molecular weight heparins, unfractionated heparin, fondaparinux and vitamin K antagonists) and evidence-based, internationally recognised guidelines. Limited knowledge of guidelines, concerns about bleeding risks and the inconvenience of parenteral administration and routine coagulation monitoring contribute to non-adherence to guidelines. Newer oral anticoagulants such as rivaroxaban, dabigatran etexilate, apixaban and edoxaban, which do not have the limitations of established anticoagulants, have been developed.

METHOD

Phase III randomised controlled trials for the treatment of acute VTE or for secondary prevention of recurrent VTE were identified in the PubMed and ClinicalTrials.gov databases. The search was limited to phase III studies and performed up to 26 March 2012 with the terms 'rivaroxaban OR Xarelto', 'dabigatran OR Pradaxa', 'apixaban OR Eliquis' and 'edoxaban OR DU-176b OR Lixiana'.

FINDINGS

A total of ten phase III studies, four published (three rivaroxaban, one dabigatran), three completed with results presented at recent congresses (dabigatran), and three ongoing (two apixaban, one edoxaban) were identified. Published and completed studies showed that rivaroxaban and dabigatran provided effective and convenient short-term treatment for deep vein thrombosis and VTE, respectively, when compared with standard of care, and showed superiority for long-term prevention of recurrent VTE when compared with placebo. Currently, rivaroxaban is the only newer anticoagulant that has been approved in Europe for the treatment of deep vein thrombosis and prevention of recurrent VTE.

CONCLUSIONS

Based on results of completed trials, rivaroxaban and dabigatran both may reduce the incidence of secondary complications of VTE and associated socioeconomic costs. Introduction of these newer anticoagulants is likely to have a substantial impact on clinical practice.

Knee length versus thigh length graduated compression stockings for prevention of deep vein thrombosis in postoperative surgical patients

BACKGROUND

Graduated compression stockings (GCS) are a valuable means of thromboprophylaxis in hospitalised postoperative surgical patients. But it is still unclear whether knee length graduated compression stockings (KL) or thigh length (TL) stockings are more effective.

OBJECTIVES

The aim of this review was to systematically analyse the randomised, controlled trials that have evaluated the effectiveness of KL versus TL GCS as a thromboprophylaxis tool in hospitalised patients undergoing various types of surgery.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2012) and CENTRAL (2012, Issue 1). The authors searched MEDLINE and EMBASE (until 27 February 2012) and they also searched the reference lists of relevant articles to identify additional trials.

SELECTION CRITERIA

Randomised controlled trials published in any language on KL versus TL GCS used as a thromboprophylaxis tool in hospitalised patients of any age and either gender.

DATA COLLECTION AND ANALYSIS

Data extraction was undertaken independently by two review authors using data extraction sheets and confirmed by the third review author.

MAIN RESULTS

Three studies, with a combined total of 496 patients, matched the inclusion criteria for this review. All three included studies evaluated the role of KL and TL in thromboprophylaxis among a group of postoperative patients. These studies showed no significant difference in the ability of the two modalities of leg compression to reduce the incidence of deep vein thrombosis in postoperative patients. In both the fixed-effect model (odds ratio (OR) 1.55, 95% confidence interval (CI) 0.78 to 3.07, P = 0.21) and random-effects model (OR 1.32, 95% CI 0.43 to 4.06, P = 0.63) KL graduated compression stockings were as effective as TL stockings in thromboprophylaxis. However, there was significant heterogeneity (Tau(2) = 0.50; Chi(2) = 4.12, df = 2 (P = 0.13); I(2) = 51%) among trials. Results of this review may be considered weak because there was significant heterogeneity among included trials resulting from inadequate randomisation techniques, allocation concealment, power calculations and the absence of intention-to-treat analysis.

AUTHORS' CONCLUSIONS

This review found that there is insufficient high quality evidence to determine whether or not KL and TL GCS differ in their effectiveness in terms of reducing the incidence of deep vein thrombosis (DVT) in hospitalised patients.  A major multicentre RCT is required to address this issue. In the meantime, the decision on which type of stocking to use in clinical practice is likely to be influenced by factors such as patient compliance, ease of use and cost implications.

Role of new anticoagulants for the prevention of venous thromboembolism after major orthopaedic surgery and in hospitalised acutely ill medical patients

Anticoagulation therapy for the prevention of venous thromboembolic events is indicated in patients after major orthopaedic surgery and in hospitalised acutely ill medical patients, who have a high or moderate risk of venous thromboembolism (VTE), respectively. Clinical trials have clearly demonstrated that short-term anticoagulation reduces the risk of VTE in these patient groups and that longer-term anticoagulation is beneficial for some indications. Evidence-based guidelines for thromboprophylaxis have been developed based on these studies. However, despite these guidelines, thromboprophylaxis is still underused, or used suboptimally, in many patients. This is, in part, because of the limitations of traditional anticoagulants such as unfractionated heparin, low- molecular-weight heparin, synthetic pentasaccharides, and vitamin K antagonists. Newer oral anticoagulants, such as rivaroxaban, apixaban, and dabigatran etexilate, have certain advantages over traditional agents. They can be administered orally at a fixed dose without routine coagulation monitoring and have minimal food and drug interactions. These characteristics may result in better adherence to guidelines and improved patient outcomes. This review provides an overview of phase III clinical trial data for these newer anticoagulants in major orthopaedic surgery and in hospitalised acutely ill medical patients, and discusses their potential for extended use in the post-hospital discharge setting. All three newer oral anticoagulants are approved in many countries for the prevention of VTE after hip replacement or knee replacement surgery in adult patients, and it is likely that these drugs will contribute considerably towards reducing the substantial healthcare burden associated with VTE.

Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

OBJECTIVE

To determine the incidence of venous thromboembolism (VTE) among patients with traumatic spinal cord injury (TSCI) in acute care settings that is attributable to extended length of stay (LOS), insurance status, and access to rehabilitation.

DESIGN

Population-based, retrospective cohort study.

SETTING

Levels I through III and undesignated trauma centers.

PARTICIPANTS

Patients with acute TSCI (N=3389) discharged from all acute care hospitals in South Carolina from 1998 through 2009, and a representative sample of patients with TSCI (n=186) interviewed 1 year later.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

VTE while in acute care.

RESULTS

Annual incidence of TSCI is 67.2 per million in the state of South Carolina, while the cumulative incidence of VTE is 4.1%. Patients with TSCI who developed VTE were nearly 4 times more likely (odds ratio [OR], 3.98; 95% confidence interval [CI], 2.57-6.17) to have been those who stayed 12 days or longer in acute care after adjusting for covariates. The adjusted mean LOS in acute care was 32.0 days (95% CI, 27.7-37.2) for patients with TSCI who had indigent insurance versus 11.3 days (95% CI, 4.9-17.6) for Medicare, and 18.5 days (95% CI, 14.5-22.5) for commercial insurance after adjusting for VTE, disposition, and year of discharge. Only 20% of the persons under indigent care received rehabilitation from accredited rehabilitation facilities in contrast to 60% under commercial insurance.

CONCLUSIONS

Fewer patients with TSCI under indigent care received postacute rehabilitation compared with Medicare or commercial insurance. Insurance status remains a major barrier to timely transfer to rehabilitation, leading to protracted LOS in acute care with increased risk of VTE.

The underutilization of venous thromboembolism prophylaxis in medical patients

Venous thromboembolism (VTE), long been recognized as a preventable complication of hospitalization, is becoming more widely recognized as a risk for both medical and surgical patients. Recommendations exist for VTE prophylaxis (PPX) in medical patients, but current research shows that the utilization of these guidelines is suboptimal. The rates of VTE PPX are lower than recommended rates, and in those patients receiving PPX, the type, dosage, or duration is not in accordance with recognized recommendations. The recommendations and protocols for medical patients that are currently available should be followed, and as new research is developed and reviewed, current practice should be changed to reflect it. The clinical nurse specialist is in a unique position to assimilate the current recommendations into practice and to enhance patient care by virtue of having multiple spheres of influence, capable of influencing institution policy, patient, family, nurse, and physician education, and direct patient care. The VTE PPX is not overused, but underused, and institutions, physicians, and nurses all need to be cognizant of patient risk for VTE with the need to treat prophylactically and initiate PPX according to the American College of Chest Physicians guidelines.

Economic impact of an electronic alert system to prevent venous thromboembolism in hospitalised patients

OBJECTIVES

The prevention of venous thromboembolism (VTE) is a priority for improved safety in hospitalised patients. Worldwide, there is growing concern over the undersuse of appropriate thromboprophylaxis. Computerised decision support improves the implementation of thromboprophylaxis and reduces inpatient VTE. However, an economic assessment of this approach has not yet been performed.

OBJECTIVES

To evaluate the economic impact of an electronic alert (e-alert) system to prevent VTE in hospitalised patients over a 4year period.

PATIENTS/METHODS

 All hospitalised patients at a single institution during the first semesters of 2005-2009 (n=32280) were included. All cases of VTE developed during hospitalisation were followed and direct costs of diagnosis and management collected.

RESULTS

 E-alerts achieved a sustained reduction of the incidence of in-hospital VTE, OR 0.50 (95% CI, 0.29-0.84), the impact being especially significant in medical patients, OR 0.44 (95% CI, 0.22-0.86). No increase in prophylaxis-related bleeding was observed. In our setting, the mean direct cost (during hospitalisation and after discharge) of an in-hospital VTE episode is €7058. Direct costs per single hospitalised patient were reduced after e-alerts from €21.6 to €11.8, while the increased use of thromboprophylaxis and the development of e-alerts meant €3 and €0.35 per patient, respectively. Thus, the implementation of e-alerts led to a net cost saving of €6.5 per hospitalised patient. Should all hospitalised patients in Spain be considered, total yearly savings would approach €30million.

CONCLUSIONS

 E-alerts are useful and cost-effective tools for thromboprophylaxis strategy in hospitalised patients. Fewer thromboembolic complications and lower costs are achieved by its implementation.

Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with cancer. The risk of VTE varies over the natural history of cancer, with the highest risk occurring during hospitalization and after disease recurrence. Patient and disease characteristics are associated with further increased risk of VTE in this setting. Specific factors include cancer type (eg, pancreatic cancer, brain cancer, lymphoma) and the presence of metastatic disease at the time of diagnosis. VTE is a significant predictor of increased mortality during the first year among all types and stages of cancer, with metastatic disease reported to be the strongest predictor of mortality. VTE is also associated with early death in ambulatory patients with cancer. These data highlight the need for close monitoring, prompt treatment, and appropriate preventive strategies for VTE in patients with cancer. The American Society of Clinical Oncology and the National Comprehensive Cancer Network have issued guidelines regarding the prophylaxis and treatment of patients with cancer. This review summarizes the impact of VTE on patients with cancer, the effects of VTE on clinical outcomes, the importance of thromboprophylaxis in this population, relevant ongoing clinical trials examining the prevention of VTE, and new pharmacologic treatment options.

The importance of appropriate prophylaxis for the prevention of venous thromboembolism in at-risk medical patients

BACKGROUND

Venous thromboembolism (VTE), which encompasses both deep-vein thrombosis and pulmonary embolism, is a significant healthcare problem, leading to considerable morbidity, mortality and resource utilisation.

AIMS

This review discusses the adherence to VTE guideline recommendations and the available clinical evidence on the appropriate type, dose and duration of VTE prophylaxis.

METHODS

A literature survey was conducted using Pub Med and EMBASE to identify publications related to appropriate thromboprophylaxis in medically ill patients at risk of VTE.

RESULTS

Despite evidence from clinical trials and national guidelines, VTE prophylaxis in medically ill patients remains underutilised. The use of unfractionated heparin three-times-daily, low-molecular-weight heparin once-daily and fondaparinux once-daily has demonstrated effectiveness in clinical trials of medically ill patients. However, controversy exists about the use of unfractionated heparin twice-daily, and fondaparinux has not yet received US Food and Drug Administration approval for VTE prophylaxis in medically ill patients.

CONCLUSION

It is important for clinicians to have an understanding of the evidence-based literature when selecting an appropriate drug, at the appropriate dose, for the appropriate duration for VTE prophylaxis in medically ill patients. VTE prophylaxis in medically ill patients is cost-effective, and drugs that are expensive may still be cost-effective when considering improved efficacy and/or safety. Recently, the underutilisation of VTE prophylaxis has led to the involvement of government and other regulatory agencies in an attempt to increase appropriate VTE prophylaxis in US hospitals and improve the clinical and economic outcomes in medical patients at risk of VTE.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.