Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start)

Healthcare utilization and expenditures among patients with venous thromboembolism following gastrointestinal cancer surgery

BACKGROUND

We sought to assess healthcare utilization and expenditures among patients who developed venous thromboembolism (VTE) after gastrointestinal cancer surgery.

METHODS

Patients who underwent surgery for esophageal, gastric, hepatic, biliary duct, pancreatic, and colorectal cancer between 2013 and 2020 were identified using the MarketScan database. Entropy balancing was performed to obtain a cohort that was well balanced relative to different clinical covariates. Generalized linear models were used to compare 1-year postdischarge costs among patients who did and did not develop a postoperative VTE.

RESULTS

Among 20,253 individuals in the analytical cohort (esophagus [n = 518 {2.6%}], stomach [n = 970 {4.8%}], liver [n = 608 {3.0%}], bile duct [n = 294 {1.5%}], pancreas [n = 1511 {7.5%}], colon [n = 12,222 {60.3%}], and rectum [n = 4130 {20.4%}]), 894 (4.4%) developed VTE. Overall, most patients were male (n = 10,656 [52.6%]), aged between 55 and 64 years (n = 10,372 [51.2%]), and were employed full time (n = 11,408 [56.3%]). On multivariable analysis, VTE was associated with higher inpatient (mean difference [MD], $17,547; 95% CI, $15,141-$19,952), outpatient (MD, $8769; 95% CI, $7045-$10,491), and pharmacy (MD, $2811; 95% CI, $2509-$3113) expenditures (all P < .001). Furthermore, patients who developed VTE had higher out-of-pocket costs for inpatient (MD, $159; 95% CI, $66-$253) and pharmacy (MD, $122; 95% CI, $109-$136) services (all P < .001).

CONCLUSION

Among privately insured patients aged <65 years, VTE was associated with increased healthcare utilization and expenditures during the first year after discharge.

Just What the Doctor Ordered: Missed Ordering of Venous Thromboembolism Chemoprophylaxis Is Associated With Increased VTE Events in High-risk General Surgery Patients

OBJECTIVE

To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations.

BACKGROUND

The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing.

METHODS

All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events.

RESULTS

A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality.

CONCLUSIONS

pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

Modes of Failure in Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is associated with potentially preventable in-hospital morbidity and mortality. Although evidence-based guidelines are widely available, their application in clinical practice varies markedly. VTE prophylaxis involves a multistep dynamic process that can fail at various points during hospital stay. Our aim was to identify defects in VTE prophylaxis. Upon admission, our patients undergo VTE risk stratification and orders for prophylaxis are entered. All patients that fulfill the criteria for the Patient Safety Indicator (PSI)-12, as defined by the Agency for Healthcare Research and Quality, are prospectively entered in a database. From a review of 138 PSI-12 patients, only 21 had correct risk stratification and appropriate chemoprophylaxis during their hospital stay; 70 had been incorrectly stratified, with 28 of these patients receiving incorrect prophylaxis due to incorrect stratification, thus delaying the correct administration of chemoprophylaxis for >24 h. Inadequate application of mechanical prophylaxis was noted in 114 patients. VTE prophylaxis relies on correct risk stratification, ordering appropriate pharmacomechanical measures and, finally, the delivery of this treatment throughout the hospital stay. A large percentage of patients who had a thromboembolic complication received inadequate prophylaxis. This study identifies potential areas for intervention to improve VTE prophylaxis.

The effect of information technology intervention on using appropriate VTE prophylaxis in non-surgical patients: A systematic review and meta-analysis

Introduction

Clinical decision support systems (CDSSs) play an important role in summarizing the best clinical practices, thereby promoting high standards of care in specific medical fields. These systems can serve as tools for gaining knowledge and mediating between clinical guidelines and physicians thereby providing the right information to the right person at the right time.

Objective

This review aims to evaluate the effect of CDSSs on adherence to guidelines for venous thromboembolism (VTE) prophylaxis and VTE events compared to routine care without CDSSs in non-surgical patients.

Methods

In order to conduct a systematic literature review, the published studies were identified through screening EMBASE, the international clinical trials registry, OVID, Cochrane database, PubMed, ISI Web of Science, and Scopus databases, from 1982 to March 2021. The included studies were reviewed by two independent reviewers; the proportion of patients that correctly received VTE prophylaxis has been next extracted for further analysis. Additionally, patients were divided into two groups: CDSS-recommended VTE prophylaxis and routine care without using a CDSS.

Results

Twelve articles (three randomized controlled trials, seven prospective cohort trials, and two retrospective cohort trials) were in fine analyzed. The use of CDSSs is found to be associated with a significant increase in the rate of using the appropriate prophylaxis for VTE ( p < 0.05) and a significant decrease in the incidence of VTE ( p < 0.05).

Conclusion

Implementation of CDSSs can help improving the appropriate use of VTE prophylaxis in non-surgical patients. Further, evidence-based and interventional studies on the development of CDSSs can provide more in-depth knowledge on both this tool design and efficiency.

Two novel risk factors for postoperative venous thromboembolism: A reconsideration of standard risk assessment and prophylaxis

BACKGROUND

Postoperative venous thromboembolism (VTE) is usually preventable with adequate prophylaxis. In an institutional study, patients with emergency operations (EO), multiple operations (MO), and perioperative sepsis (PS) were more likely to develop VTE despite standard prophylaxis.

METHODS

General surgery patients in the NSQIP database from 2011 to 2014 were stratified into VTE and non-VTE groups, and statistical analyses were performed.

RESULTS

Among 1,610,086 patients, 13,673 (0.8%) were diagnosed with VTE. The VTE odds ratios for patients with EO, MO and PS were 1.4 (95%CI:1.3-1.5), 1.9 (95%CI:1.7-2.0), and 2.4 (95%CI:2.2-2.5), respectively. VTE odds ratios increased with concurrence of two factors (EO+PS: 2.0 (95%CI:1.9-2.2)) (EO+MO: 2.3 (95%CI:1.9-2.7)) (MO+PS: 2.5 (95%CI:2.2-2.7)) and further still for patients with all three factors (2.7, 95%CI:2.4-3.0).

CONCLUSION

General surgery patients with EO, MO, or PS have a greater likelihood of developing postoperative VTE. These factors are not necessarily captured in contemporary risk assessment models that guide chemoprophylaxis, and so these high-risk patients may receive insufficient prophylaxis.

Prevention and treatment of venous thromboembolism in hospital and the community: a research programme including the ExACT RCT

Background

Deep-vein thrombosis and pulmonary embolism, collectively known as venous thromboembolism when clots are formed in the venous circulation, are common disorders that are often unprovoked (i.e. there is no obvious reason for the clot occurring). Some people, after having an unprovoked clot, are at a high risk of developing another, or at risk of developing a secondary clot, most importantly in the lungs. Furthermore, in the long term, some patients will develop circulation problems known as post-thrombotic syndrome. The aim of this programme was to improve the understanding of both the prevention and the treatment of thrombosis in people at the highest risk of recurrence.

Objectives

To clarify if it is possible to identify those people at the highest risk of having a recurrent venous thromboembolism, and if it is possible to prevent this happening by giving anticoagulation treatment for longer. To clarify if it is possible to identify those people at the highest risk of developing post-thrombotic syndrome. To document the current knowledge level about prevention and treatment of venous thromboembolism. To find what the barriers are to implementing measures to prevent venous thromboembolism. To find the most cost-effective means of treating venous thromboembolism.

Design

Mixed methods, comprising a randomised controlled trial, qualitative studies, cost-effectiveness analyses and questionnaire studies, including patient preferences.

Setting

UK general practices and hospitals, predominantly from the Midlands and Shropshire.

Participants

Adults attending participating anticoagulation clinics with a diagnosis of first unprovoked deep-vein thrombosis or pulmonary embolism, and health-care professionals, patients and other stakeholders who were involved in the prevention and treatment of venous thromboembolism.

Intervention

Extended treatment with oral anticoagulation therapy (2 years) versus standard care (treatment with oral anticoagulation therapy for at least 3 months).

Results

Work package 1 demonstrated that extended anticoagulation for up to 2 years was clinically effective and cost-effective in reducing the incidence of recurrent venous thromboembolism, with a small increase in the risk of bleeding. There was no difference in post-thrombotic syndrome incidence or severity, or quality of life, between those undergoing the extended treatment and those receiving the standard care. Work package 2 identified five common themes with regard to the prevention of hospital-acquired thrombosis: communication, knowledge, role of primary care, education and training, and barriers to patient adherence. Work package 3 suggested that extended anticoagulation with novel oral anticoagulants was cost-effective only at the £20,000-per-quality-adjusted life-year level for a recurrence rate of between 17.5% and 22.5%, depending on drug acquisition costs, while identifying a strong patient preference for extended anticoagulation based on a fear of recurrent venous thromboembolism.

Limitations

The major limitation was the failure to reach the planned recruitment target for work package 1.

Conclusions

Extended anticoagulation with warfarin for a first unprovoked venous thromboembolism is clinically effective and cost-effective and is strongly preferred by patients to the alternative of not having treatment. There are significant barriers to the implementation of preventative measures for hospital-acquired thrombosis. Further research is required on identifying patients in whom it is safe to discontinue anticoagulation, and at what time point following a first unprovoked venous thromboembolism this should be done.

Trial registration

Current Controlled Trials ISRCTN73819751 and EudraCT 2101-022119-20.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.

Updated clinical models for VTE prediction in hospitalized medical patients

Venous thromboembolism (VTE) occurring in hospitalized medical patients is associated with increased length of hospitalization, high rate of acute care hospital transfer, longer inpatient rehabilitation and multiplication of health-care costs. Identification of acutely ill hospitalized medical patients eligible for thromboprophylaxis is a sophisticated process. Global VTE risk stems from the combination of predictors related with the acute medical illness, comorbidities, associated treatments and patients' intrinsic risk factors. Emerging clinical risk factors related to underlying pathologies should be considered when VTE risk is assessed. The Padua Prediction Score (PPS), the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE-RAM) and the Geneva Risk Score are three robust risk assessment models (RAM) which underwent extensive external validation in cohorts of acutely ill hospitalized medical patients. The development of the IMPROVE bleeding risk assessment model and the identification of D-Dimer increase as a biomarker-predictor of VTE are some steps forward for personalized thromboprophylaxis. The beneficial impact of the RAMs in VTE prevention is already seen by the decrease of in-hospital VTE rates when RAMs are incorporated in electronic alert systems.

Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study

Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5 years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.

Prophylaxis against Deep Venous Thrombosis in Patients Hospitalized in Surgical Wards in One of the Hospitals in Iran: Based on the American College of Chest Physician's Protocol

Background

There is not enough studies to determine the frequency of using the prophylaxis against deep venous thrombosis (DVT) based on the American College of Chest Physician's (ACCP) guidelines in Iran. Thus, providing such statistics is essential to improve thromboprophylaxis in hospital. The present study aimed to determine the frequency of using the prophylaxis against DVT based on ACCP guidelines in patients hospitalized in surgical wards in one of teaching hospital in Ilam, Iran.

Methods

In a cross-sectional, the samples were selected among medical records of patients who were hospitalized and underwent surgery in surgical wards of the hospital from April 2012 to September 2013. Type of prophylaxis was determined based on ACCP guidelines. After reviewing inclusion and exclusion criteria, patients' data were extracted from medical records based on required variables.

Results

In reviewing 169 qualified samples, 46.2% (78 patients) were women. Of these, 132 patients were at risk of DVT and needed prophylaxis, only 39 patients (29.5%) received prophylaxis. Thromboprophylaxis based on ACCP guidelines had been fully implemented only in 30 cases (22.7%) of patients with the risk of DVT.. The highest thromboprophylaxis was in the intensive care unit (46.6%) and neurosurgery (37.5%), and the least rate was in urology (0%).

Conclusions

As the results of this study, there are differences between clinical practice and the ACCP guidelines recommendation in prophylaxis against DVT. Thromboprophylaxis has not been implemented based on ACCP guidelines in more than 75% of patients with the risk of DVT. Thus, new strategies are needed to implement thromboprophylaxis against DVT in Iranian hospitals.

Venous Thromboembolism Rates in Transferred Patients: A Cross-Sectional Study

BACKGROUND

Patients undergoing a transfer during a hospitalization may be more likely to be diagnosed with a venous thromboembolism (VTE) than patients who are not transferred.

OBJECTIVE

To determine whether transferred patients have an increased prevalence of VTE diagnosis.

DESIGN

This was a cross-sectional study comparing VTE diagnosis rates between transferred patients and non-transferred patients. For the years 2012-2014, the University HealthSystem Consortium database of multiple community and academic medical centers throughout the United States was parsed using ICD-9 VTE diagnosis codes and patient's point of origin.

PATIENTS

Patients were included in the analysis as transferred patients if their point of origin was a skilled nursing facility, another acute care facility or another facility. Non-transferred patients were those whose point of origin was a clinic or those with a non-facility point of origin.

MAIN MEASURES

The primary comparison of VTE prevalence during hospitalization between transferred and non-transferred patients in the years 2012-2014. Subgroup analysis looked at level I trauma status and case mix index (CMI) to determine whether these had an effect on VTE prevalence.

KEY RESULTS

From 2012 to 2014, a total of 225 unique hospitals and 12,036,029 patients were analyzed, and the prevalence of VTE in transferred patients and non-transferred patients was 3.43% and 1.91% (RR 1.80; 95% CI 1.78-1.81; P <0.001), respectively. VTE prevalence in transferred versus non-transferred patients at level I trauma centers was 3.42% versus 1.88% (RR = 1.82; 95% CI 1.80-1.85; P <0.001). The 3-year average CMI of transferred versus non-transferred patients was 3.53 versus 2.26 (P < 0.001).

CONCLUSIONS

Transferred patients have a higher prevalence of VTE than non-transferred patients, regardless of level I trauma designation. Higher VTE rates in transferred versus non-transferred patients was minimally correlated with CMI.

Venous Thromboembolism Prophylaxis: Inadequate and Overprophylaxis When Comparing Perceived Versus Calculated Risk

Guidelines for venous thromboembolism (VTE) prophylaxis recommend appropriate risk stratification using risk estimation models as high risk or low risk followed by initiation of chemical or mechanical prophylaxis, respectively. We explored adherence to guidelines on the basis of the documentation of VTE prophylaxis. A retrospective medical record review of 437 consecutive adult patients (≥18 years) admitted to general medical wards under medicine service between January 1, 2015, and March 1, 2015, was performed. The primary outcome was appropriateness of risk stratification using the Padua Prediction Score. Secondary outcomes were appropriateness of type of prophylaxis (chemical vs mechanical) and cost-benefit analysis. We observed appropriate stratification based on the documented risk (compared with the calculated risk) in 54.9% of the patients (40.8% with low risk vs 72.1% with high risk; P<.001). Overall, 182 of 240 low-risk patients received unnecessary chemical prophylaxis, whereas 23 of 197 high-risk patients without contraindications for chemical prophylaxis received mechanical or no prophylaxis. No clinical VTE events were noted in the patients inappropriately assigned to mechanical or no prophylaxis. Also, 67.3% of patients with both low documented and low calculated risk and 74.5% of patients with low documented and high calculated risk received chemical prophylaxis, consistent with a tendency toward overtreatment. A total of 4068 annualized patient-days ($77,652/y) of inappropriate chemical prophylaxis were administered. In conclusion, estimation of the risk of VTE based on clinical impression was not congruent with the risk calculated using risk prediction models and was associated with a tendency toward overtreatment. These data support the inclusion of VTE risk calculators in electronic health record systems.

Deep-vein thrombosis: A United States cost model for a preventable and costly adverse event

Preventable venous thromboembolism (VTE) and “appropriate” type, dose, and duration of prophylaxis are emerging concepts. Contemporary definitions by key quality organisations, including the World Health Organization, have shifted towards “preventable” VTE being considered an adverse event or adverse drug event. A decision tree and cost model were developed to estimate the United States health care costs for total deep-vein thrombosis (DVT), total hospital-acquired DVT, and total “preventable” DVT. Annual cost ranges were obtained in 2010 US dollars for total ($7.5 to $39.5 billion), hospital-acquired ($5 to $26.5billion), and preventable ($2.5 to $19.5 billion) DVT costs. When the sensitivity analysis was applied – taking into consideration higher incidence rates and costs – annual US total, hospital-acquired, and “preventable” DVT costs ranged from $9.8 to $52 billion, $6.8 to $36 billion, and $3.4 to $27 billion, respectively.

New paradigms in venous thromboprophylaxis of medically ill patients

Acutelly-ill hospitalised medical patients are at risk of venous thromboembolism (VTE), both in-hospital and in the immediate post-discharge period, and mortality from VTE is thought to be particularly high in this patient population. However, despite previous mandates from international antithrombotic guidelines such as those of the American College of Chest Physicians (ACCP) for the "universal" use of thromboprophylaxis in hospitalised medical patients, global audits suggest that implementation of thromboprophylaxis continues to be challenging because of the perceived higher risk of bleeding and lower risk of VTE than that reported in clinical trials. Recent population-based studies also reveal that a "universal" hospital-only thromboprophylactic strategy does not reduce the community burden of VTE from this population, which may constitute nearly one quarter of the attributable risk of VTE. Lastly, four large randomised placebo-controlled trials of extended thromboprophylaxis have failed to show a definitive net clinical benefit in hospitalised medical patients. Recent large-scale efforts in deriving and validating scored VTE and bleed risk assessment models (RAMs) have been completed in the medically-ill population. In addition, an elevated D-dimer as a new biomarker to identify at-VTE risk medically ill patients has also undergone prospective evaluation. This paper will review current concepts of VTE and bleed risk in hospitalised medical patients, both in the hospital as well as the post-hospital discharge period, and will discuss new paradigms of thromboprophylaxis in this population using an individualised, patient-centered approach.

Worldwide adherence to ACCP guidelines for thromboprophylaxis after major orthopedic surgery: A systematic review of the literature and meta-analysis

INTRODUCTION

Increased risk of venous thromboembolism following major orthopedic surgery (MOS) is well described. The American Academy of Chest Physician (ACCP) has generated evidence-based recommendations for thromboprophylaxis; however, there is a gap between guidelines recommendations and clinical practice. The aim of this study is to compare worldwide adherence rates to the last 4 editions of ACCP guidelines for thromboprophylaxis after MOS.

MATERIALS AND METHODS

A systematic review of literature and meta-analysis was performed. Studies reporting adherence to ACCP guidelines between January 2004 and October 2014 were included. Adherence rates after MOS for in-hospital (IH), extended (EXT), and global thromboprophylaxis (in-hospital plus extended) were assessed.

RESULTS

Of 3993 titles, 13 studies reporting data of 35,303 patients were selected. Studies assessing the 6th, 7th or 8th editions of ACCP guidelines were found. No studies evaluating the 9th edition were available. For MOS, global adherence rates for the 6th, 7th and 8th editions were 62% (95% CI: 61%-63%), 70% (95% CI: 69%-71%), and 42% (95% CI: 41%-43%), respectively. Likewise, in-hospital adherence was 52% (95% CI: 50%-54%), 51% (95% CI: 50%-52%) and 85% (95% CI: 84%-86%). For extended prophylaxis, adherence rates were reported only for the 8th edition (59%; 95% CI: 58%-60%).

CONCLUSIONS

Adherence to ACCP recommendations for thromboprophylaxis during hospitalization has increased over time. Nevertheless, adherence rates to global thromboprophylaxis decrease due to an insufficient implementation of recommendations after discharge.

Could a Coagulation Nurse Liaison Improve Compliance With Venous Thromboembolism Prophylaxis in Medical Patients?

Medical patients worldwide are undertreated with venous thromboembolism prophylaxis. Our hypothesis was that the rate of prophylactic anticoagulation therapy for high-risk patients would improve with the use of a coagulation nurse liaison. Six months after appointing a nurse for this role, prophylaxis rates significantly improved, and patients were more likely to receive appropriate thromboprophylaxis. A coagulation nurse liaison substantially improves thromboprophylaxis in a medical ward.

Venous thromboembolism in cancer patients: an underestimated major health problem

Venous thromboembolism (VTE) is a major health problem among patients with cancer, its incidence in this particular population is widely increasing. Although VTE is associated with high rates of mortality and morbidity in cancer patients, its severity is still underestimated by many oncologists. Thromboprophylaxis of VTE now considered as a standard of care is still not prescribed in many institutions; the appropriate treatment of an established VTE is not yet well known by many physicians and nurses in the cancer field. Patients are also not well informed about VTE and its consequences. Many studies and meta-analyses have addressed this question so have many guidelines that dedicated a whole chapter to clarify and expose different treatment strategies adapted to this particular population. There is a general belief that the prevention and treatment of VTE cannot be optimized without a complete awareness by oncologists and patients. The aim of this article is to make VTE a more clear and understood subject.

Venous Thromboembolism Prophylaxis in Acutely Ill Veterans With Respiratory Disease

This observational study assessed the rate and appropriateness of pharmacologic venous thromboembolism prophylaxis in veterans with pulmonary disease who were admitted to the hospital for a nonsurgical stay.

Clinical decision support systems to improve utilization of thromboprophylaxis: a review of the literature and experience with implementation of a computerized physician order entry program

OBJECTIVE

A literature review was conducted of studies investigating the effectiveness of paper- and computer-based clinical decision support systems (CDSS) used with or without educational programs designed to increase the use of venous thromboembolism (VTE) prophylaxis.

METHODS

Medline was searched on August 9, 2010, without limits on publication year, but with restrictions to English-language articles only. The search terms used were "venous thromboembolism," "deep vein thrombosis," "pulmonary embolism," "prophylaxis," "thromboprophylaxis," "computerized," "computerised," "decision support," "alerts," "reminder," "paper system," "risk assessment," and "risk score." All types of studies regarding the effects of CDSS on VTE prophylaxis rates were included. Studies were included if ≥ 1 post-implementation outcome was measured, such as rates of VTE, rates of prophylaxis prescribing, or guideline-adherence measures.

RESULTS

Studies evaluating paper-based CDSS used different strategies, including risk-assessment forms with prophylaxis recommendations, standard order sets, and preprinted sticker reminders on patient notes. Paper-based systems consistently improved prophylaxis rates; however, in most studies, there was still room for improvement. Furthermore, the effect of paper-based CDSS on VTE rates was not conclusively established. Studies evaluating computer-based systems used approaches including risk-assessment models integrated in the computerized physician order entry system, with or without alerts, and automatic reminders on operating schedules.

CONCLUSION

Computerized systems are associated with substantial improvements in the prescribing of appropriate prophylaxis and reductions in VTE events, particularly in medical patients. More robust systems can be established with computer-based rather than paper-based CDSS. A drawback of computerized systems is that some hospitals may not have adequate information technology system resources.

Rates of pharmacologic venous thromboembolism prophylaxis in hospitalized patients with active ulcerative colitis: results from a tertiary care center

BACKGROUND

Inflammatory bowel disease (IBD) patients are at increased risk for venous thromboembolism (VTE) compared to the general population. Practice guidelines recommend pharmacologic prophylaxis for IBD inpatients.

AIM

Our aim was to determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC) inpatients at a tertiary referral center. We also assessed potential predictors of pharmacologic prophylaxis.

METHODS

We conducted a retrospective cohort study of 377 UC patients between January 1st, 2007 and December 31st, 2011. The medical record of each patient was examined to determine whether pharmacologic VTE prophylaxis was ordered and administered. We conducted multiple logistic regression to determine predictors of pharmacologic prophylaxis.

RESULTS

The overall VTE pharmacologic prophylaxis rate was 67.6%. The rate of patients admitted to the medical service was 57.4% compared to 93.5% for those admitted to surgery. In medical patients who received pharmacologic VTE prophylaxis, 34.0% of ordered doses were not given compared to 17.4% of doses in surgical patients (P<0.001). In the multiple logistic regression analysis, having an additional VTE risk factor (OR 2.46, 95% CI 1.41-4.30), extensive colitis (OR 2.26, 95% CI 1.32-3.87) or being admitted to a surgical service (OR 12.03, 95% CI 5.29-27.38) was associated with VTE pharmacologic prophylaxis.

CONCLUSIONS

A substantial proportion of medical patients admitted with UC were not ordered for VTE pharmacologic prophylaxis despite current guidelines. Even in patients who were ordered for pharmacologic prophylaxis, one third of doses were not given. Inappropriate prophylaxis may lead to unnecessary morbidity and mortality.

A review of venous thromboembolism prophylaxis for hospitalized medical patients

In the last decade, greater focus has been directed toward venous thromboembolism (VTE) prophylaxis in hospitalized, non-surgical patients. Both deep venous thrombosis and pulmonary embolism are potentially preventable causes of patient morbidity and mortality related to hospitalization. Despite the availability of high-quality, evidence-based guidelines for VTE prevention, there is compelling evidence that many hospitalized patients do not receive appropriate VTE prevention measures. Hospitalists play an important role in the implementation of appropriate VTE prophylaxis measures for this patient population; thus, knowledge of updated recommendations is vital to their practice, as well as patient safety. We provide a comprehensive evidence-based clinical review of VTE prophylaxis for nonsurgical hospitalized patients, including risk factors and risk assessment, indications for prophylaxis, recommended therapeutic options, and updates from recently released practice guidelines by the American College of Physicians and the American College of Chest Physicians, published in 2011 and 2012, respectively.

Bridging efforts to longitudinally improve and evaluate VEnous thromboembolism prophylaxis uptake in hospitalized cancer patients through Interprofessional Teamwork (BELIEVE IT): a study by Princess Margaret Cancer Centre

INTRODUCTION

Despite demonstrable risk of venous thromboembolism (VTE), thromboprophylaxis continues to be underutilized in hospitalized cancer patients. Our study evaluated institutional VTE prophylaxis rates after devising a series of strategic interventions to longitudinally improve adherence rates over a period of eight years.

METHODS AND MATERIALS

Between 2004 and 2012, a series of interventions were implemented to improve the thromboprophylaxis rate among patients with solid tumours hospitalized at our institution using quality improvement methodology. Interventions included development of guidelines and institutional policies coupled with educational in-services for physicians, nurses and pharmacists and engagement of the Cancer Quality Committee. Thromboprophylaxis rates were monitored to assess response to interventions.

RESULTS

At the outset in 2004, 11 of 57 (19.3%) eligible patients received appropriate pharmacological prophylaxis and formed the baseline of our analysis. Post-2009 policy implementation and educational sessions, 46.5% of an eligible 185 inpatients were administered thromboprophylaxis. Following a two-year grace period to allow for policy acceptance, three audits were conducted in 2011 for which an average prophylaxis rate of 62.3% resulted. In 2012, following another round of educational sessions, a 96.7% rate was achieved and maintained ten weeks later. Minimal bleeding risk was observed during this eight year initiative.

CONCLUSION

A reproducible 96.7% prophylaxis uptake rate was the result of our perseverance and persistence in believing that culture change was inevitable through continuously collaborating with stakeholders at all levels.

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.

Review of thromboembolic prophylaxis in patients attending Cork University Hospital

BACKGROUND

Although preventable, venous thromboembolism remains a common cause of hospital acquired morbidity and mortality. Guidelines, such as the one produced by the American College of Chest Physicians (ACCP), are aimed at reducing hospital associated venous thromboemboli. Unfortunately the majority of studies have revealed inadequate adherence to these guidelines.

OBJECTIVE

The objective of this study was to evaluate the use of venous thromboembolism prophylaxis at Cork University Hospital.

SETTING

Cork University Hospital, Wilton, Cork, Ireland.

METHODS

Data from the patient's chart, drug kardex and laboratory results were recorded during April 2010. A Caprini score, a venous thromboembolism risk factor assessment tool, was subsequently calculated for each patient based on data collected. Appropriate prophylaxis was determined after examining data collected, Caprini score and prophylactic regime according to the ACCP 8th edition guidelines.

MAIN OUTCOME MEASURE

Primary outcome was to analyse adherence to VTE prophylaxis guidelines.

RESULTS

A total of 394 patients met the inclusion criteria and were reviewed, of which, 60% (n = 236) were medical and 37% (n = 146) were surgical patients. In total 63% of patients received some form of venous thromboembolism prophylaxis. Furthermore, 54% of medical and 76% of surgical patients received prophylaxis. However only 37% of the patients studied received appropriate thromboprophylaxis according to the ACCP 8th edition guidelines (Geerts et al. in chest 133(6 Suppl):381S-453S, 2008). Additionally 51% of surgical and 27% of medical patients received appropriate prophylaxis.

CONCLUSION

Data collected from Cork University Hospital revealed poor adherence to international venous thromboembolism prophylaxis guidelines. As stated in the ACCP 8th edition guidelines, every hospital should develop a formal strategy for venous thromboembolism prevention (Geerts et al. in chest 133(6 Suppl):381S-453S, 2008). In order to improve adherence to guidelines, Cork University Hospital should develop, implement and re-evaluate a specific protocol for venous thromboembolism prophylaxis.

Rate of deep-vein thrombosis and pulmonary embolism during the care continuum in patients with acute ischemic stroke in the United States

BACKGROUND

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are frequent and life-threatening complications of ischemic stroke. We evaluated rates of symptomatic DVT/PE, and of in-hospital and post-discharge thromboprophylaxis in patients with acute ischemic stroke (AIS).

METHODS

In a retrospective US database analysis, data were extracted from the Premier Perspective™-i3 Pharma Informatics linked database for patients aged ≥18 years who were hospitalized for ischemic stroke from January 2005 to November 2007, and who had ≥6 months' continuous plan enrollment prior to index hospitalization. Patients discharged to an acute-care facility or with atrial fibrillation were excluded. Prophylaxis was evaluated during index hospitalization and for 14 days' post-discharge. DVT/PE rates were calculated during index hospitalization and up to 30 days post-discharge.

RESULTS

A total of 1524 patients were included; 46.1% received pharmacological and/or mechanical prophylaxis in-hospital (28.3%, 11.4% and 12.3% received unfractionated heparin, enoxaparin and mechanical prophylaxis, respectively). 6.4% of patients received outpatient pharmacological prophylaxis; warfarin was most frequently prescribed (5.9%). Total mean ± standard deviation length of index hospitalization was 3.0 ± 2.5 days. Mean prophylaxis duration in all patients was 0.9 ± 1.5 days in-hospital and 1.7 ± 6.9 days post-discharge. Symptomatic DVT/PE occurred in 25 patients overall (1.64%), with an inpatient rate of 0.98% and an outpatient rate of 0.66%.

CONCLUSIONS

Approximately 1% of patients with AIS experienced symptomatic in-hospital and/or post-discharge DVT/PE. Although 46% received prophylaxis in-hospital, only 6% received prophylaxis in the outpatient setting. This highlights the need for sustained thromboprophylaxis prescribing across the continuum of care.

Antithrombotic medication use and bleeding risk in medically ill patients after hospitalization

BACKGROUND

Hospitalized medically ill patients receiving antithrombotic medications experience increased risk of bleeding. We examined antithrombotic use, bleeding rates, and associated risk factors at 30 days post discharge.

METHODS

This retrospective database analysis included nonsurgical patients aged ≥40 years hospitalized for ≥2 days during 2005 to 2009. Previously cited, validated International Classification of Diseases, Ninth Revision, Clinical Modification codes for major bleeding were used to define clinically relevant bleeding.

RESULTS

Of the 327,578 patients, 9.1% received antithrombotic medications, of which 3.7% were anticoagulants. Rates of major and minor bleeding were 1.8% and 7.1%, respectively. Preindex gastroduodenal ulcer, thromboembolic stroke, blood dyscrasias, liver disease, and rehospitalization were the strongest predictors of major bleeding. Other risk factors included increasing age, male gender, and hospital stay of ≥3 days.

CONCLUSIONS

Careful consideration of these demonstrated bleed-associated comorbidities before initiating anticoagulation or combining antithrombotic medications in medically ill patients may improve strategies for prevention of postdischarge thromboembolism.

Is development of postoperative venous thromboembolism related to thromboprophylaxis use? A case-control study in the Veterans Health Administration

BACKGROUND

Observational studies continue to report thromboprophylaxis underuse for postoperative pulmonary embolism/deep vein thrombosis (pPE/DVT) despite the long-standing existence of prevention guidelines. However, data are limited on whether thromboprophylaxis use differs between patients developing pPE/DVT versus those who do not or on why prophylaxis is withheld.

METHODS

Administrative data (2002-2007) from 28 Veterans Health Administration hospitals were screened for discharges with (1) pPE/DVT as flagged by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator software and (2) pharmacoprophylaxis-recommended procedures, and the medical records were reviewed to ascertain true pPE/DVT cases. Controls were selected by matching cases by hospital, age, sex, diagnosis-related group, and predicted probability for developing pPE/DVT, and who underwent a pharmacoprophylaxis-recommended procedure. Records were assessed for "appropriate pharmacoprophylaxis use," defined primarily per American College of Chest Physicians (ACCP) guidelines, and reasons for anticoagulant nonuse.

RESULTS

The 116 case-control pairs were similar in terms of demographics, surgery type, ACCP risk category, and appropriate pharmacoprophylaxis rates overall. Of the highest-risk patients, respective pharmacoprophylaxis rates among cases and controls were 88% versus 92% among hip/knee replacements and 31% versus 48% among cancer patients. Of the cases and controls who did not receive appropriate pharmacoprophylaxis, only about 25% had documented contraindications. Reviewers identified contraindications in 14% of cases and 9% of controls.

CONCLUSIONS

Similarities in preventive pPE/DVT practice between cases and controls suggest that pPE/DVTs occur despite implementation of guideline-adherent practices.

Chinese orthopedic surgeons' practice regarding postoperative thromboembolic prophylaxis after major orthopedic surgery

OBJECTIVE

To assess Chinese surgeon practice of thromboprophylaxis following major orthopedic surgery.

METHODS

A questionnaire survey was conducted amongst Chinese orthopedic surgeons. A total of 293 surgeons were surveyed concerning five key aspects of thromboembolic prophylaxis after major orthopedic surgery at the proseminar of Chinese guidelines for prevention of venous thromboembolism (VTE) after major orthopedic surgery in January of 2009.

RESULTS

Totally, 208 surgeons (71.0%) responded, successfully completing the questionnaire. Of them, 57.6% respondents selected combined basic, mechanical, and pharmacologic methods for thromboprophylaxis; 51.0% respondents prefer starting prophylaxis 12-24 hours after surgery; 60.3% surgeons would use chemoprophylaxis for 7-10 days; 47.6% respondents prefer VTE prevention based on patients' special conditions and needs upon discharge."Safety" was the most repeated and emphasized factor during VTE prophylaxis.

CONCLUSIONS

Multimodal thromboprophylaxis is frequently used after major orthopedic surgery. Half surgeons prefer to start chemoprophylaxis 12-24 hours after surgery. Thromboprophylaxis regimen varies for discharged patients.

Venous thromboembolism: annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates

Healthcare reform is upon the United States (US) healthcare system. Prioritisation of preventative efforts will guide necessary transitions within the US healthcare system. While annual deep-vein thrombosis (DVT) costs have recently been defined at the US national level, annual pulmonary embolism (PE) and venous thromboembolism (VTE) costs have not yet been defined. A decision tree and cost model were developed to estimate US health care costs for total PE, total hospital-acquired PE, and total hospital-acquired "preventable" PE. The previously published DVT cost model was modified, updated and combined with the PE cost model to elucidate the same three categories of costs for VTE. Direct and indirect costs were also delineated. For VTE in the base model, annual cost ranges in 2011 US dollars for total, hospital- acquired, and hospital-acquired "preventable" costs and were $13.5-$27.2, $9.0-$18.2, and $4.5-$14.2 billion, respectively. The first sensitivity analysis, with higher incidence rates and costs, demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $32.1-$69.3, $23.7-$51.5, and $11.9-$39.3 billion, respectively. The second sensitivity analysis with long-term attack rates (LTAR) for recurrent events and post-thrombotic syndrome and chronic pulmonary thromboembolic hypertension demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $15.4-$34.4, $10.3-$25.4, and $5.1-$19.1 billion, respectively. PE costs comprised a majority of the VTE costs. Prioritisation of effective VTE preventative strategies will reduce significant costs, morbidity and mortality within the US healthcare system. The cost models may be utilised to estimate other countries' costs or VTE-specific disease states.

Venous thromboembolism prophylaxis of acutely ill hospitalized medical patients. Are we under-treating our patients?

Venous thromboembolism (VTE) is frequent in patients hospitalized in Internal Medicine wards. It carries a considerable morbidity and mortality. Recommendations for use of anticoagulation are graded 1A in leading evidence-based consensus guidelines. Implementation of these guidelines is suboptimal. Lack of awareness seems to be an important factor for the low implementation rate of thromboprophylaxis in Internal Medicine wards, but other factors may be equally important: some clinicians find the data favoring thromboprophylaxis unconvincing or believe that pharmacological prevention is too risky for the average medical inpatient. The following review will show that although there is a dispute about the clinical importance of some manifestations of thromboembolic disease, anticoagulation significantly reduces the risk for clinically relevant VTE. The bleeding risk in most patients is low and does not outweigh the benefit of treatment. Pharmacological or mechanical thromboprophylaxis is cost-effective when administered to at-risk patients. Better awareness and judicious use of risk assessment models should help the attending physician to balance the risk of VTE against the potential bleeding risk.

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.

Duration of venous thromboembolism risk across a continuum in medically ill hospitalized patients

BACKGROUND

Patients hospitalized for medical illness are at increased risk of venous thromboembolism (VTE), but the duration of risk is not well understood.

OBJECTIVE

To assess incidence and time course of symptomatic VTE following hospitalization for medical illness in a large, real-world patient population.

DESIGN

Data were extracted from the Thomson Reuters MarketScan(®) Inpatient Drug Link File.

PATIENTS

Those hospitalized with cancer, heart failure, severe lung disease, or infectious disease from 2005 to 2008.

MEASUREMENTS

The cumulative VTE risk over 180 days after admission was calculated using Kaplan-Meier analysis. VTE hazard was calculated on a daily basis and smoothed through LOESS regression.

RESULTS

The analysis included 11,139 medically ill patients, 46.7% and 8.8% of whom received pharmacological thromboprophylaxis during hospitalization and after discharge, respectively. The mean duration of prophylaxis during hospitalization was 5.0 days. Of the 11,139 patients, 366 (3.3%) experienced a symptomatic VTE event. VTE events were most frequent during days 0-9 (97 events), followed by days 10-19 (82 events). The mean length of hospital stay was 5.3 days, and 56.6% of all VTE events occurred after discharge. VTE hazard peaked at day 8, with 1.05 events per 1000 person-days.

CONCLUSIONS

The time course of VTE in medical patients shows that risk of symptomatic VTE is highest during the first 19 days after hospital admission, and extends into the period after discharge. Future research is warranted to investigate risks and benefits of reducing the incidence of VTE after discharge, including the role of improving thromboprophylaxis practices in the inpatient setting and extending thromboprophylaxis after hospitalization.

Performance measures for improving the prevention of venous thromboembolism: achievement in clinical practice

Venous thromboembolism (VTE) is a common complication during and after hospitalization for acute medical illness or surgery. Despite the existence of evidence-based guidelines for VTE prevention, real-world prescribing practices are frequently suboptimal. Specific performance measures relating to VTE prevention and treatment have been developed by US health care organizations to increase adherence with best-practice recommendations and ultimately reduce the number of preventable VTE events. Two measures developed by the Surgical Care Improvement Project have been endorsed by the National Quality Forum (NQF) and focus on VTE prevention. In addition, six measures have been developed recently by The Joint Commission in collaboration with the NQF; three measures relate to VTE prevention and three focus on treatment. To attain widespread achievement of these performance goals, it is essential to raise awareness of their existence and specifications. It is also imperative that hospitals develop and implement effective VTE protocols. The use of multiple, active strategies, such as computer decision support systems with regular audit and feedback, may be particularly valuable approaches to improve current practices within an integrated quality improvement program. During practical implementation of VTE protocols at Norton Healthcare (Kentucky's largest healthcare system), strong leadership, physician engagement, and caregiver accountability were identified as key factors influencing the process. As such, more hospitals may be able to increase adherence with guidelines, improve achievement of quality goals, and help to reduce the substantial burden associated with avoidable VTE.

Improving prevention and treatment of venous thromboembolism: clinical trial results

BACKGROUND

Venous thromboembolism (VTE) incurs considerable socioeconomic costs, partly owing to the fact that the treatment and prevention of VTE via effective thromboprophylaxis remains suboptimal in the inpatient and outpatient settings of many healthcare systems. A number of organizations-including the National Quality Forum, The Joint Commission, and the Centers for Medicare and Medicaid Services-have established measures to assess and reduce the healthcare burden of VTE. These improvement strategies focus on increasing the use of thromboprophylaxis, implementing existing guidelines, and improving awareness.

FINDINGS

Based on clinical trial results, the oral anti-coagulants rivaroxaban, apixaban, and dabigatran etexilate have been approved in many countries for the prevention of VTE in patients after elective hip or knee replacement surgery. Recently, dabigatran etexilate and rivaroxaban have also been approved in the US for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. In addition, rivaroxaban is currently the only newer anti-coagulant that has been approved in Europe for the treatment of deep vein thrombosis and for the long-term prevention of recurrent VTE. These oral anti-coagulants have several advantages over established anti-coagulants, including no need for routine coagulation monitoring and only minimal food and drug interactions. These characteristics, together with convenient oral administration, may improve adherence and quality of life for patients, which could result in reductions in the rate of VTE.

CONCLUSIONS

These three oral agents have several advantages over established anti-coagulants and could, therefore, address the unmet needs of patients, physicians, and healthcare systems, with the potential to reduce the burden of anti-coagulant management and the occurrence of VTE.

Risk assessment models for cancer-associated venous thromboembolism

Venous thromboembolism (VTE) is common in cancer patients, and is associated with significant morbidity and mortality. Several factors, including procoagulant agents secreted by tumor cells, immobilization, surgery, indwelling catheters, and systemic treatment (including chemotherapy), contribute to an increased risk of VTE in cancer patients. There is growing interest in instituting primary prophylaxis in high-risk patients to prevent incident (first-time) VTE events. The identification of patients at sufficiently high risk of VTE to warrant primary thromboprophylaxis is essential, as anticoagulation may be associated with a higher risk of bleeding. Current guidelines recommend the use of pharmacological thromboprophylaxis in postoperative and hospitalized cancer patients, as well as ambulatory cancer patients receiving thalidomide or lenalidomide in combination with high-dose dexamethasone or chemotherapy, in the absence of contraindications to anticoagulation. However, the majority of cancer patients are ambulatory, and currently primary thromboprophylaxis is not recommended for these patients, even those considered at very high risk. In this concise review, the authors discuss risk stratification models that have been specifically developed to identify cancer patients at high risk for VTE, and thus might be useful in future studies designed to determine the potential benefit of primary thromboprophylaxis.

Venous thromboembolism pharmacy intervention management program with an active, multifaceted approach reduces preventable venous thromboembolism and increases appropriate prophylaxis

Two concepts relating to venous thromboembolism (VTE) prevention have recently emerged-"appropriate" prophylaxis and "preventable" VTE. We evaluated whether a human alert, as part of a pharmacy intervention program, can increase appropriate prophylaxis and decrease preventable symptomatic VTE in hospitalized patients. This prospective study with retrospective data collection was conducted utilizing data from 1879 patients in 2006 as a control cohort. The intervention cohort data were from 1646 patients during 2007, after program implementation. The rate of appropriate prophylaxis increased from 23.8% in 2006 to 37.9% in 2007 (odds ratio 1.8; 95% confidence interval [CI] = 1.6-2.1; P < .0001). Preventable VTE incidence was reduced by 74% (95% CI = 44%-88%) from 18.6 to 4.9 per 1000 patient discharges in 2006 and 2007, respectively (P = .0006). In conclusion, a pharmacy-led multifaceted intervention can significantly increase the rates of appropriate prophylaxis and significantly reduce the incidence of preventable VTE in hospitalized patients.

Inpatient and outpatient occurrence of deep vein thrombosis and pulmonary embolism and thromboprophylaxis following selected at-risk surgeries

BACKGROUND

Despite evidence-based guidelines on prevention, many surgical patients remain at risk of deep vein thrombosis (DVT) and pulmonary embolism (PE).

OBJECTIVE

To quantify the provision of thromboprophylaxis and proportion of US surgical patients who develop DVT/PE, both in the hospital and postdischarge.

METHODS

This study was an observational, retrospective database analysis of national managed care data. Data were extracted from the Premier Perspective-i3 Pharma Informatics linked database on patients hospitalized between January 2005 and November 2007 for orthopedic surgery or major abdominal surgery. Patients were included if they were aged 18 years or older at the time of hospitalization and had at least 6 months of continuous plan enrollment prior to index hospitalization. Patients discharged to an acute care facility or with atrial fibrillation were excluded. Prophylaxis status was evaluated during index hospitalization and for 14 days postdischarge. The proportion of patients who developed DVT/PE was calculated during index hospitalization and for 30 days postdischarge.

RESULTS

The analysis included 19,581 patients following major abdominal surgery and 5315 patients following orthopedic surgery. Inpatient pharmacologic or mechanical thromboprophylaxis was received by 58.7% of abdominal surgery patients and 85.0% of orthopedic surgery patients; outpatient pharmacologic prophylaxis was received by 1.6% and 58.4% of patients, respectively. Total mean (SD) prophylaxis duration was 1.7 (3.7) days following abdominal surgery and 13.0 (11.6) days following orthopedic surgery. The proportion of abdominal surgery patients who developed symptomatic DVT/PE was 1.6%; 3.1% of orthopedic surgery patients developed symptomatic DVT/PE, with almost 40% of the events occurring postdischarge.

CONCLUSIONS

Continued efforts are needed to prevent DVT/PE after abdominal and orthopedic surgery. Initiatives that encourage outpatient prophylaxis must ensure that appropriate prophylaxis of adequate duration is prescribed to all at-risk surgical patients to further reduce DVT/PE across the continuum of care. Pharmacists can play an important role in optimizing continuity of patient care in the prevention of DVT, in providing anticoagulation services that can help reduce the incidence of DVT/PE and bleeding complications, and in helping hospitals achieve performance measures.

Crew Resource Management and VTE Prophylaxis in Surgery

Despite the availability of safe and effective prophylaxis, appropriate use of venous thromboembolism (VTE) prophylaxis in surgical patients remains suboptimal. Multifaceted quality improvement (QI) activities are needed for sustained improvement at the individual institution level. This work describes a QI initiative for VTE prophylaxis in surgery that combined clinical education with Crew Resource Management (CRM)—a set of principles and techniques for communication, teamwork, and error avoidance used in the aviation industry. Surveys of clinicians participating in the initiative demonstrated immediate and retained confidence and increased knowledge in identifying process-related factors leading to errors, applying CRM to patient care, and identifying VTE prophylaxis candidates and guideline-recommended prophylaxis regimens. Reviews of patient charts preinitiative and postinitiative demonstrated performance improvement in meeting guideline recommendations for the timing, inpatient duration, and use of VTE prophylaxis beyond discharge. This new model joins continuing medical education with CRM to improve the appropriate use of VTE prophylaxis in surgery.

Preventing venous thromboembolism following orthopedic surgery in the United States: impact of special populations on clinical outcomes

Clinical trials of anticoagulants often exclude special populations. We assessed the proportion of special populations in real-world orthopedic surgery and the incidence of venous thromboembolism (VTE)-related outcomes. Data on patients with hip (n = 11 483) or knee replacement (n = 19 390) were extracted from IMS' PharMetrics Patient-Centric Database. There was high prevalence of patients aged ≥75 years (20.3%), CYP3A4-inhibitor use (21.5%), and chronic warfarin use (9.5%). Venous thromboembolism events were increased with each increasing year of age (hip: odds ratio [OR] 1.02, 95% confidence interval [CI] = 1.01-1.03; knee: OR 1.01, 95%CI = 1.00-1.02) and chronic warfarin use (hip: OR 1.56, 95%CI = 1.13-2.17; knee: OR 1.33, 95%CI = 1.03-1.72); in hip patients with renal insufficiency (OR1.61, 95%CI=1.11-2.36); and in knee patients with atrial fibrillation (OR 1.41, 95%CI = 1.06-1.88). Major bleeding was higher in hip patients with hepatic impairment (OR 21.99, 95%CI = 2.04-236.62), each increasing year of age (OR 1.08, 95%CI = 1.01-1.15), and chronic warfarin use (OR 7.11, 95%CI = 1.16-43.46). Special populations are prevalent in real-world orthopedic surgery, which may impact VTE-related outcomes.

Real-World Rates of In-hospital and Postdischarge Deep-Vein Thrombosis and Pulmonary Embolism in At-Risk Medical Patients in the United States

Hospitalized medical patients are at risk of deep-vein thrombosis (DVT) and pulmonary embolism (PE). We evaluated inpatient and postdischarge DVT/PE and thromboprophylaxis rates in US medical patients, using patient admissions from January 2005 to November 2007 in the Premier Perspective™-i3 Pharma Informatics database. Among 15 721 patients with cancer, congestive heart failure, severe lung disease, and infectious disease, 39.0% received inpatient thromboprophylaxis, with the highest rate in patients with cancer (51.9%). In all, 3.4% received outpatient pharmacological prophylaxis. Mean ± SD prophylaxis duration was 2.2 ± 5.7 days. Overall, 3.0% of inpatients had symptomatic DVT/PE, and an additional 1.1% of patients were rehospitalized for DVT/PE or treated in the outpatient setting. Patients with infectious disease had the highest rate of DVT/PE (4.6%). Inpatient DVT/PE and prophylaxis rates of the different medical conditions had a negative correlation ( R 2 = 0.72). This analysis demonstrates the burden of DVT/PE and highlights the underuse of thromboprophylaxis across the continuum of care.