Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: a survey of healthcare professionals

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center

INTRODUCTION

Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes.

METHODS

We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk.

RESULTS

Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%.

CONCLUSION

Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

Knowledge, risk assessment, practices, self-efficacy, attitudes, and behaviour's towards venous thromboembolism among nurses: A systematic review

AIM

This study reviewed the literature on nurses' knowledge, risk assessment practices, self-efficacy, attitudes, and behaviours towards venous thromboembolism (VTE).

DESIGN

A systematic review following PRISMA guidelines.

METHODS

CINAHL (via EBSCO), MEDLINE (via PubMed), and Web of Science were electronic databases used to find studies published from 2010 to November 2020 in English language. A Hoy critical appraisal checklist was used to assess the risk of bias and methodologic quality.

RESULTS

This study included fourteen studies conducted on 8628 Registered Nurses. Nine of the fourteen studies examined nurses' general knowledge level regarding VTE, and five showed that most nurses had a good knowledge of VTE. Of the 14 studies, six assessed nurses' risk assessment knowledge regarding VTE, and three showed that nurses had low knowledge of VTE risk assessment. Eleven studies assessed nurses' practices concerning VTE prophylaxis; 5 of the 11 studies reported that nurses had poor and unsatisfactory levels of VTE practice. Three of the 14 studies showed that nurses had low self-efficacy and varied beliefs. The most frequent recommendations were to create continuous educational programs and in-service training programs (n = 11), followed by creating institutional protocols standardizing VTE (n = 6).

CONCLUSIONS

Comprehensive educational programs and campaigns based on well-established and standardized tools should be provided to nurses to improve their VTE knowledge.

Nursing Care and Barriers for Prevention of Venous Thromboembolism in Total Knee and Hip Arthroplasty Patients: A Qualitative Study

Purpose

To determine barriers to preventing venous thromboembolism in total knee and hip arthroplasty patients by surgical nurses.

Methods

This qualitative study used a phenomenological approach. The semi-structured interview questionnaire included two questions focused on nursing care practices for VTE prevention and barriers faced during VTE prophylaxis in total knee and hip arthroplasty patients. Study data were collected from 10 surgical nurses through semi-structured interviews in July 2021.

Results

After analyzing the data, two main themes, five categories, and fourteen subcategories were developed. The main themes included "Nursing care" and "Barriers." Two categories were reflected in terms of nursing care: general care and mechanical prophylaxis. Regarding barriers, the analysis of the interview reflected three main categories: "lack of professional competence", "work conditions challenges", and "resistance from patients".

Conclusion

Educational institutions must play a critical role in preparing surgical nurses by establishing clinical nurse specialist programs and post-graduate diplomas programs that sufficiently prepare nurses for clinical settings.

Compliance of non-pharmacological preventive practice of venous thromboembolism among Jordanian nurses

Many practices, such as non-pharmacological preventive practices, have demonstrated significant improvement and reduced the venous thromboembolism incidence. This study aims at investigating the compliance with non-pharmacological preventive practice of venous thromboembolism guidelines among Jordanian intensive care and medical and surgical nurses. Descriptive and cross-sectional with the non-participant observational design was used. This study recruited 271 registered nurses in adult medical-surgical units and intensive care units of 12 different government hospitals in Jordan's middle and north regions. The observational checklist included 10 preventive practices based on the non-pharmacological preventive of venous thromboembolism guidelines. In the observational checklist, the highest score was 20, and the lowest was 0. If the nurse received equal to or higher than (>14) score were classified as sufficient compliance, while insufficient compliance was (≤14) score. The observations period started from September 2019 until March 2020. The participants' overall mean venous thromboembolism compliance score was insufficient compliance (10.6 ± 1.6). The majority of nurses were classified as insufficient compliance 67%. "Doing foot exercise and early ambulation 2 times per day 50.3%" and "checked the integrity of the patient's skin at regular intervals 50.0%" were the highest practices done rightly and completely by half of the participants. The participants who had a bachelor of nursing degree, staff nurse, and works in the intensive care unit, are less experienced and have no previous venous thromboembolism education reported low venous thromboembolism compliance. This study presents expanded compliance regarding venous thromboembolism preventive practices among Jordanian intensive care and medical & surgical nurses, so the policymakers need to develop an initiative to improve nurses' compliance.

Acceptance of clinical decision support system to prevent venous thromboembolism among nurses: an extension of the UTAUT model

Background

Venous thromboembolism has been a major public health problem and caused a heavy disease burden. Venous thromboembolism clinical decision support system was proved to have a positive influence on the prevention and management of venous thromboembolism. As the direct users, nurses' acceptance of this system is of great importance to support the successful implementation of it. However, there are few relevant studies to investigate nurses' acceptance and the associated factors are still unclear.

Objective

To investigate the determinant factors of nurses' acceptance of venous thromboembolism clinical decision support system with the modified Unified Theory of Acceptance and Use of Technology.

Methods

We designed a questionnaire based on the modified Unified Theory of Acceptance and Use of Technology and then a cross-sectional survey was conducted among nurses in a tertiary hospital in Nanjing, China. Statistically, a Structural Equation Modeling -Partial Least Squares path modeling approach was applied to examine the research model.

Results

A total of 1100 valid questionnaires were recycled. The modified model explained 74.7%, 83.0% and 86% of the variance in user satisfaction, behavioral intention and user behavior, respectively. The results showed that performance expectancy (β = 0.254, p = 0.000), social influence (β = 0.136, p = 0.047), facilitating conditions (β = 0.245, p = 0.000), self-efficacy (β = 0.121, p = 0.048) and user satisfaction (β = 0.193, p = 0.001) all had significant effects on nurses' intention. Although effort expectancy (β = 0.010, p = 0.785) did not have a direct effect on nurses' intention, it could indirectly influence nurses' intention with user satisfaction as the mediator (β = 0.296, p = 0.000). User behavior was significantly predicted by facilitating conditions (β = 0.298, p = 0.000) and user intention (β = 0.654, p = 0.001).

Conclusion

The research enhances our understanding of the determinants of nurses' acceptance of venous thromboembolism clinical decision support system. Among these factors, performance expectancy was considered as the top priority. It highlights the importance of optimizing system performance to fit the users' needs. Generally, the findings in our research provide clinical technology designers and administrators with valuable information to better meet users' requirements and promote the implementation of venous thromboembolism clinical decision support system.

A Prospective Study Evaluating Patterns of Responses to the Caprini Score to Prevent Venous Thromboembolism After Interventional Treatment for Varicose Veins

Background

Venous thromboembolism (VTE) is a critical complication of varicose vein treatments. The Caprini Score (CS) is an established tool to assess patients’ VTE risks. One disadvantage is the number of questions required, some of them referring to a low incidence of disease, even lower in patients seeking an elective procedure. These elements take time and may result in filling errors if the CS is not filled out by a properly trained health professional.

Objective

To establish a response pattern in CS, with emphasis on questions that usually have a negative answer and propose a simpler adaptative digital version without changing the original structure of the tool.

Methods

two hundred and twenty-seven patients in the pre-surgical treatment of varicose veins were enrolled prospectively and submitted to the CS evaluation.

Results

The pattern of dichotomous responses could be divided arbitrarily into four subgroups considering the percentage of positive responses: none (11 items), less than 3% (13 items), between 3% and 20% (5 items), and more than 20% (8 items). Of the 12 CS questions related to illnesses that occurred in the last month, ten had had no responses, and 2 were less than 3%.

Conclusion

There is a pattern in the CS responses of patients with an indication of surgical treatment of varicose veins. Many of the CS questions are not helpful in this scenario and may result in filling errors performed by untrained providers. An adaptative version of the CS might benefit varicose veins surgery VTE risk stratification

Effectiveness of flipped classroom among nursing students on venous thromboembolism (VTE)

Background

Modern innovative education approaches are crucial to be incorporated into nursing education that leads to improving evidence-based teaching strategies, and closes the gap between theory and practice, as well as to prepare the nursing students to their future workplaces.

Aim

Aim of the study was evaluation the effectiveness of the flipped classroom method among nursing students regarding VTE basic knowledge, risk factors, and prophylaxis.

Subjects and Methods

This study was implemented in a Faculty of Nursing in Northern Cyprus at Nicosia, and used pre-test and post-test, and interventional design. A total of 100 bachelor-degree nursing students were composed the sample of the study. The Implementation of the study was conducted in three phases including pre-test, educational intervention, and post-test. Data were evaluated using the independent-sample t test.

Results

The findings of the study showed statistically significant improvement in the overall mean scores of all VTE after the educational intervention through flipped classroom. Students classified the strength points with four themes; deep motive learning, technology support, team-based learning, and satisfaction.

Conclusions

Our results support the effectiveness of the flipped classroom method in nursing education; the method may be useful for developing of educational strategies in nursing.

Development of the Nurses' Intention to Use Deep Vein Thrombosis Preventive Measures Questionnaire

BACKGROUND AND PURPOSE

Deep vein thrombosis (DVT) is a serious condition resulting in poor patient outcomes. Therefore, methods to improve nurses' use of preventive measures for DVT are paramount. The purpose of this study was to develop and validate an instrument that captured nurses' intentions to use DVT preventive measures.

METHODS

Instrument development occurred in several stages stemming from the recommended formatted structure associated with theory of planned behavior (TPB). Content validity was established with a panel of experts, then the instrument was pilot tested with a sample of intensive care unit (ICU) nurses.

RESULTS

The final instrument consisted of four subscales, each subscale was tested with four items by content validity index (CVI) ranging between 0.8 and 1.0, and an overall S-CVI/Ave of 0.93.

CONCLUSIONS

The instrument demonstrated high content validity. Future research will test the instrument for psychometric properties.

[Prevention of thromboembolic disease in elderly patients admitted to medical wards]

OBJECTIVES

To determine the suitability of the prevention of thromboembolic disease in elderly patients admitted to medical departments, as well as some associated factors, such as the measures required in order to improve quality and safety.

PATIENTS AND METHODS

A retrospective study in a tertiary level hospital that included elderly patients that were admitted to medical departments. A simple, non-proportional, randomised sample was used, stratified by department. The risk was measured using the Padua prediction model and the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) adjusting depending on the number of discharges. A Lot Quality Assurance Sampling (LQAS) plan was used with three levels, good, (standard 95%, threshold 70%), acceptable (standard 95%, threshold 50%), and not acceptable.

RESULTS

A total of 72 cases from 8 departments were evaluated. Just over half (51.4%) of patients had a high risk of thromboembolic disease (Padua≥4), and 23.6% of bleeding (IMPROVE≥7). Besides the advanced age, the adjusted scores were particularly due to cancer (22%) and reduced mobility (19%) for Padua, and male gender (13%) and renal failure (12%) for IMPROVE. The adjusted overall suitability was 57.5% (95%CI: ±19.0%). The OR for suitable conduct on not starting medication, 1.56 (95%CI: 1.07-2.26). The suitability by department was not uniform: all the lots were acceptable, in 3 with level "good" and in 5 with "acceptable".

CONCLUSIONS

The suitability of thromboembolic prophylaxis in the study hospital maintains acceptable levels, although not homogeneous. There is an opportunity for improvement that must be taken. The data obtained may help in deciding interventions, with LQAS being useful to optimise the evaluation effort.

Nurses' knowledge, attitudes, and behaviors toward venous thromboembolism prophylaxis: How to do better

OBJECTIVES

To investigate the cognition of nurses on the control and treatment of venous thromboembolism in China, thereby providing suitable countermeasures for clinical venous thromboembolism prophylaxis and treatment.

METHODS

In December 2019, a total of 1121 registered nurses from a university-affiliated hospital were selected to answer the self-designed and electronic questionnaire (Wenquanxing: www.wjx.cn/), which was designed to evaluate the nurses' knowledge (21 items), attitudes (6 items), and behaviors (9 items) toward venous thromboembolism prophylaxis. Descriptive, correlation, and regression analyses were conducted for data analysis.

RESULTS

Of the included 1121 nurses, only 55.43% nurses selected 100% correct answer. The influencing factors of knowledge included the department, education, professional ranks, and venous thromboembolism nursing experience. The nurses from ICU department gained the highest score, but the nurses from pediatrics department obtained the lowest score. The nurses with higher education level and professional ranks, and nursing experiences achieved higher scores. The total positive response rate for the attitude-related items was 68.54%. Nurses were primarily concerned about the financial penalty due to the inability to complete the work (49.0%). An increasing workload is the second primary concern of nurses (40.8%). The increasing medical cost, extension of hospital stay, and exacerbation of doctor-patient conflicts were the most serious difficulties involved in venous thromboembolism prophylaxis. The total correct score rate for the behaviors was 56.19%. Nearly half of the nurses could not offer advice for venous thromboembolism patients. The nursing experience, department, and years of work were related to the scores of knowledge-related items (all P < 0.05).

CONCLUSIONS

The overall knowledge level of the nurses was not optimistic. Although their general attitude toward venous thromboembolism prophylaxis was positive, their behaviors were influenced by many factors. Administrators should, therefore, make countermeasures to deal with these problems.

Written reports of adverse events in acute care-A discourse analysis

Adverse health care events are a global public health issue despite major efforts, and they have been acknowledged as a complex concern. The aim of this study was to explore the construction of unsafe care using accounts of adverse events concerning the patient, as reported by patients, relatives, and health care professionals. Twenty-nine adverse events reported in an acute care setting in a Swedish university hospital were analyzed through discourse analysis, where the construction of what was considered to be real and true in the descriptions of unsafe care was analyzed. In the written reports about unsafe events, the patient was spoken of in three different ways: (a) the patient as a presentation of physical signs, (b) the patient as suffering and vulnerable, and (c) the patient as unpredictable. When the patient's voice was subordinate to physical signs, this was described as being something that conflicted with patient safety. The conclusion was that the patient's voice might be the only sign available in the early stages of adverse events. Therefore, it is crucial for health care professionals to give importance to the patient's voice to prevent patients from harm and not unilaterally act only upon abnormal physical signs.

Nurses' objective knowledge regarding venous thromboembolism prophylaxis: A national survey study

Venous thromboembolism (VTE) is a common vascular disorder with high mortality and morbidity. Clinical nurses are a pivotal group that can serve as first-line health care providers. Lack of knowledge about VTE is an important barrier to effective nursing performance. This study aimed to determine nurses' knowledge of VTE prophylaxis through a nationwide survey across China, to understand gaps between current knowledge, and guidelines, and to help improve clinical nursing.The survey included 5 topics with 68 items on VTE, including basic knowledge, risk assessment, basic prophylaxis, physical prophylaxis, and pharmacological prophylaxis.The survey was distributed to 106 AAA-grade hospitals throughout China; 5218 valid questionnaires were submitted for analysis. There were 5097 women and 121 men respondents, with average age 30.29 ± 8.60 years. The average rate of correct responses regarding VTE knowledge was 59.90 ± 15.63%; 77.81% of subjects answered more than half of the survey items correctly. Better knowledge about thromboprophylaxis was observed among nurses who were more highly educated, more experienced, had received continuing education, intensive care unit (ICU), and lead nurses. Correct response rates were 68.39 ± 17.03%, 60.35 ± 21.01%, 75.51 ± 22.85%, 41.72 ± 17.47%, and 46.01 ± 21.22% for basic knowledge, risk assessment, basic prophylaxis, physical prophylaxis, and pharmacological prophylaxis, respectively.Respondents showed satisfactory results regarding basic prophylaxis, basic knowledge, and risk assessment for VTE; respondents had poorer knowledge regarding physical and pharmacological prophylaxis. Better mastery of knowledge about thromboprophylaxis was observed among nurses who were more highly educated, more experienced, had received continuous education, ICU, and lead nurses.This study suggested that nurse trainers should develop comprehensive educational programs that focus on low correct rate aspects. Higher-level continuous education could improve nurses' knowledge of thromboprophylaxis.

Decision making in venous thromboembolism prophylaxis: Is LWMH being inappropriately withheld from patients admitted with chronic liver disease?

Although chronic liver disease (CLD) constitutes a significant proportion of acute medical admissions, it is not known how CLD influences venous thromboembolism (VTE) prophylaxis decision making and low molecular weight heparin (LMWH) prescription. Furthermore, recent evidence suggests that VTE risk has been underestimated in CLD and that prophylactic LMWH is safe and may improve outcome in this patient group. We therefore evaluated VTE prophylaxis in patients with CLD and aimed to determine the factors contributing to decisions to prescribe LMWH. Prescription of LMWH was significantly less likely in CLD patients than in general medical patients (29% vs 55%; p < 0.01). Patients with CLD who were prescribed LMWH were more likely to have been admitted for a 'non-liver' reason than those that did not receive LMWH (19% vs 52%; p < 0.01). These preliminary results show that many patients admitted with CLD, who may benefit from LMWH prophylaxis, do not receive this therapy, because of perceived contraindications for which there may be little evidence. Decision making appears to be affected by whether an admission is 'liver' or 'non-liver' related. Prophylactic LMWH was safe in this small cohort. Further studies are warranted to further inform LMWH prescription in CLD.

Barriers and facilitators of thromboprophylaxis for medical-surgical intensive care unit patients: a multicenter survey

BACKGROUND

The objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU).

METHODS

We conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use.

RESULTS

Respondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01).

CONCLUSIONS

This multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.

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.

Strategies to enhance venous thromboprophylaxis in hospitalized medical patients (SENTRY): a pilot cluster randomized trial

BACKGROUND

Venous thromboembolism (VTE) is a common preventable cause of mortality in hospitalized medical patients. Despite rigorous randomized trials generating strong recommendations for anticoagulant use to prevent VTE, nearly 40% of medical patients receive inappropriate thromboprophylaxis. Knowledge-translation strategies are needed to bridge this gap.

METHODS

We conducted a 16-week pilot cluster randomized controlled trial (RCT) to determine the proportion of medical patients that were appropriately managed for thromboprophylaxis (according to the American College of Chest Physician guidelines) within 24 hours of admission, through the use of a multicomponent knowledge-translation intervention. Our primary goal was to determine the feasibility of conducting this study on a larger scale. The intervention comprised clinician education, a paper-based VTE risk assessment algorithm, printed physicians' orders, and audit and feedback sessions. Medical wards at six hospitals (representing clusters) in Ontario, Canada were included; three were randomized to the multicomponent intervention and three to usual care (i.e., no active strategies for thromboprophylaxis in place). Blinding was not used.

RESULTS

A total of 2,611 patients (1,154 in the intervention and 1,457 in the control group) were eligible and included in the analysis. This multicomponent intervention did not lead to a significant difference in appropriate VTE prophylaxis rates between intervention and control hospitals (appropriate management rate odds ratio = 0.80; 95% confidence interval: 0.50, 1.28; p = 0.36; intra-class correlation coefficient: 0.022), and thus was not considered feasible. Major barriers to effective knowledge translation were poor attendance by clinical staff at education and feedback sessions, difficulty locating preprinted orders, and lack of involvement by clinical and administrative leaders. We identified several factors that may increase uptake of a VTE prophylaxis strategy, including local champions, support from clinical and administrative leaders, mandatory use, and a simple, clinically relevant risk assessment tool.

CONCLUSIONS

Hospitals allocated to our multicomponent intervention did not have a higher rate of medical inpatients appropriately managed for thromboprophylaxis than did hospitals that were not allocated to this strategy.

Advances in oral anticoagulation treatment: the safety and efficacy of rivaroxaban in the prevention and treatment of thromboembolism

Arterial and venous thromboembolic diseases are a clinical and economic burden worldwide. In addition to traditional agents such as vitamin K antagonists and heparins, newer oral agents – such as the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, and the direct thrombin inhibitor dabigatran – have been shown to be effective across several indications. Rivaroxaban has been shown to have predictable pharmacokinetic and pharmacodynamic properties, including a rapid onset of action. In addition, there is no requirement for routine coagulation monitoring; and no dose adjustment is necessary for age alone, sex, or body weight. Rivaroxaban has successfully met primary efficacy and safety endpoints in large, randomized phase III trials across several indications, including: prevention of venous thromboembolism in orthopedic patients undergoing elective hip or knee replacement surgery; treatment of deep vein thrombosis and secondary prevention of deep vein thrombosis and pulmonary embolism; stroke prevention in patients with atrial fibrillation; and secondary prevention of acute coronary syndrome. Rivaroxaban and the other newer oral anticoagulants are likely to improve outcomes in the prevention and treatment of thromboembolic events, and will offer patients and physicians alternative treatment options.