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Asmamaw M, Hungnaw W, Motbainor A, Kedir HM, Tadesse TA. Incidence of thromboembolism and thromboprophylaxis in medical patients admitted to specialized hospital in Ethiopia using Padua prediction score. SAGE Open Med 2022; 10:20503121221079488. [PMID: 35223033 PMCID: PMC8864278 DOI: 10.1177/20503121221079488] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Venous thromboembolism is a major cause of mortality and morbidity among
hospitalized patients and thromboprophylaxis is one of the key strategies to
reduce such events. We aimed to assess venous thromboembolism risk using
Padua prediction score, thromboprophylaxis practice, and outcomes in
hospitalized medical patients at Tibebe Ghion Specialized Hospital, Bahir
Dar, Ethiopia. Methods: A cross-sectional study was conducted among 219 patients admitted to Tibebe
Ghion Specialized Hospital from 1 December 2018 to 31 May 2019. Data were
collected from patients’ medical records using a pre-tested data abstraction
format to collect patients’ clinical information and venous thromboembolism
risk using the Padua prediction score. We used Statistical Package for the
Social Sciences version 26 for data analysis. Descriptive statistics was
used to summarize the findings, and binary logistic regression analysis was
used to assess association between the variables of interest. Results: Reduced mobility, recent trauma and/or surgery, heart and/or respiratory
failure, and active cancer were the frequently identified venous
thromboembolism risk factors. Based on Padua prediction score, 48.4% of
patients were at high risk of developing venous thromboembolism. The venous
thromboembolism prophylaxis was given only for 55 (25.1%) patients and 15 of
them were at low risk of developing venous thromboembolism (<4 Padua
score) and were ineligible for thromboprophylaxis. Fifteen (6.84%) patients
developed venous thromboembolism events during their stay at the hospital
and 80% of them were from high risk group. The odds of females to develop
venous thromboembolism were more than 14 times higher (adjusted odds
ratio = 14.51; 95% confidence interval: 2.52–83.39, p = 0.003) than males.
Reduced mobility (adjusted odds ratio = 10.00; 95% confidence interval:
1.70–58.70), <1 month trauma and/or surgery (adjusted odds ratio = 18.93;
95% confidence interval: 2.30–155.56), active cancer (adjusted odds
ratio = 6.00; 95% confidence interval: 1.05–34.27), chronic kidney diseases
(adjusted odds ratio = 61.790; 95% confidence interval: 2.627–1453.602), and
hypertension (adjusted odds ratio = 7.270; 95% confidence interval:
1.105–47.835) were significantly associated with the risk of developing
venous thromboembolism. Conclusion: Nearly half of the patients were at risk of developing venous
thromboembolism. Underutilization of thromboprophylaxis and inappropriate
use of prophylaxis were commonly seen in Tibebe Ghion Specialized
Hospital.
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Affiliation(s)
- Mulugeta Asmamaw
- Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Wubet Hungnaw
- Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Achenef Motbainor
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Hanan Muzeyin Kedir
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tamrat Assefa Tadesse
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Huang X, Zhang L, Xu M, Yuan S, Ye Y, Huang T, Yin H, Lyu J. Anti-embolism devices therapy to improve the ICU mortality rate of patients with acute myocardial infarction and type II diabetes mellitus. Front Cardiovasc Med 2022; 9:948924. [PMID: 35928930 PMCID: PMC9343674 DOI: 10.3389/fcvm.2022.948924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anti-Embolism (AE) devices therapy is an additional antithrombotic treatment that is effective in many venous diseases, but the correlations between this medical compression therapy and cardiovascular arterial disease or comorbid diabetes mellitus (DM) are still controversial. In this study we investigated the association between compression therapy and intensive care unit (ICU) mortality in patients with a first acute myocardial infarction (AMI) diagnosis complicated with type II DM. Methods This retrospective cohort study analyzed all patients with AMI and type II DM in the Medical Information Mart for Intensive Care-IV database. We extracted the demographics, vital signs, laboratory test results, comorbidities, and scoring system results of patients from the first 24 h after ICU admission. The outcomes of this study were 28-day mortality and ICU mortality. Analyses included Kaplan-Meier survival analysis, Cox proportional-hazards regression, and subgroup analysis. Results The study included 985 eligible patients with AMI and type II DM, of who 293 and 692 were enrolled into the no-AE device therapy and AE device therapy groups, respectively. In the multivariate analysis, compared with no-AE device therapy, AE device therapy was a significant predictor of 28-day mortality (OR = 0.48, 95% CI = 0.24-0.96, P = 0.039) and ICU mortality (OR = 0.50, 95% CI = 0.27-0.90, P = 0.021). In addition to age, gender and coronary artery bypass grafting surgery, there were no significant interactions of AE device therapy and other related risk factors with ICU mortality and 28-day mortality in the subgroup analysis. Conclusions Simple-AE-device therapy was associated with reduced risks of ICU mortality and 28-day mortality, as well as an improvement in the benefit on in-hospital survival in patients with AMI complicated with type II DM.
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Affiliation(s)
- Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Luming Zhang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mengyuan Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shiqi Yuan
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yan Ye
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Haiyan Yin
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
- Jun Lyu
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3
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Rognoni C, Lugli M, Maleti O, Tarricone R. Clinical guidelines versus current clinical practice for the management of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2021; 9:1334-1344.e1. [PMID: 33744498 DOI: 10.1016/j.jvsv.2021.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/28/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is one of the major health problems worldwide with potentially serious outcomes related to mortality and morbidity. We provide a current view on how patients with DVT are managed in routine practice compared with the recommendations of published clinical guidelines. METHODS A literature review was conducted on studies reporting diagnostic and treatment patterns for acute DVT. Four dimensions were evaluated to compare the differences between clinical practice and clinical guidelines recommendations: diagnostic pathway, prescription of pharmacologic treatment and related duration, and prescription of compression therapy. For each aspect, the agreement with the corresponding guideline has been estimated as a percentage ranging from 0% (no agreement) to 100% (full agreement). RESULTS Sixteen studies reported clinical practices in 10 countries. Among them, Japan showed the highest agreement with guidelines, followed by the UK and Switzerland. Hong Kong showed the highest agreement with diagnosis guidelines, Spain for drug treatment, UK for treatment duration, and France for compression therapy. Conversely, Germany reported a complete disagreement with guidelines for diagnosis, followed by low agreement level by UK and Italy, and Switzerland reported a lower agreement level with prescription of compression therapy. CONCLUSIONS The implementation of clinical guidelines for the management of patients with DVT varies among countries from strict adherence to a complete lack of adherence. In this context, registries may be a useful tool to analyze clinical practice and produce findings that may be generalizable across populations.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy.
| | - Marzia Lugli
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery - Cardiovascular Department, Hesperia Hospital, Modena, Italy
| | - Oscar Maleti
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery - Cardiovascular Department, Hesperia Hospital, Modena, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy; Department of Social and Political Sciences, Bocconi University, Milan, Italy
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4
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Ayalew MB, Horsa BA, Zeleke MT. Appropriateness of Pharmacologic Prophylaxis against Deep Vein Thrombosis in Medical Wards of an Ethiopian Referral Hospital. Int J Vasc Med 2018; 2018:8176898. [PMID: 30105097 PMCID: PMC6076918 DOI: 10.1155/2018/8176898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/27/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Most of hospitalized patents are at risk of developing deep vein thrombosis (DVT). The use of pharmacological prophylaxis significantly reduces the incidence of thromboembolic events in high risk patients. The aim of this study was to assess appropriateness of DVT prophylaxis in hospitalized medical patients in an Ethiopian referral hospital. METHODS Cross-sectional study design was employed. Patients with a diagnosis of DVT, taking anticoagulant therapy, and those who refused to participate were excluded from the study. Two hundred and six patients were included in the study using simple random sampling method. Modified Padua Risk Assessment Model was used to determine the risk of thromboembolism. SPSS (version 21) was used for analysis. RESULT The total risk score for the study subjects ranged from 0 to 11 with a mean score of 3.41 ± 2.55. Nearly half (47.6%) of study participants had high risk to develop thromboembolism. Thrombocytopenia (platelets < 50 billion/L) or coagulopathy, active hemorrhage, and end stage liver disease (INR > 1.5) were the frequently observed absolute contraindications that potentially prevent patients from receiving thromboprophylaxis. Thromboprophylaxis use in nearly one-third (31.6%) of patients admitted in the medical ward of UoGRH was irrational. Patients who had high risk for thromboembolism are more likely to be inappropriately managed for their risk of thromboembolism and patients with thrombocytopenia or coagulopathy were more likely to be managed appropriately. CONCLUSION There is underutilization of pharmacologic thromboprophylaxis in medical ward patients. Physicians working there should be aware of risk factors for DVT and indications for pharmacologic thromboprophylaxis and should adhere to guideline recommendations.
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Affiliation(s)
- Mohammed Biset Ayalew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Gondar University, Gondar, Ethiopia
| | - Boressa Adugna Horsa
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Gondar University, Gondar, Ethiopia
| | - Meseret Tilahun Zeleke
- Department of Pharmaceutics, School of Pharmacy, College of Medicine and Health Sciences, Gondar University, Gondar, Ethiopia
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Rwabihama JP, Audureau E, Laurent M, Rakotoarisoa L, Jegou M, Saddedine S, Krypciak S, Herbaud S, Benzengli H, Segaux L, Guery E, Ambime G, Rabus MT, Perilliat JG, David JP, Paillaud E. Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial. J Am Med Dir Assoc 2018; 19:497-503. [PMID: 29580885 DOI: 10.1016/j.jamda.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention. DESIGN A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use. SETTINGS Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively. PARTICIPANTS Patients hospitalized between January 1 and May 31, 2015, in participating departments. MEASUREMENTS The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome. RESULTS We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group. CONCLUSIONS/IMPLICATIONS This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards.
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Affiliation(s)
- Jean Paul Rwabihama
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France.
| | - Etienne Audureau
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Marie Laurent
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Albert Chenevier-Henri Mondor, Créteil, France
| | - Lalaina Rakotoarisoa
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital George Clemenceau, Champceuil, France
| | - Marc Jegou
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sofiane Saddedine
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sébastien Krypciak
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Stéphane Herbaud
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Hind Benzengli
- Assistance Publique-Hôpitaux de Paris, Service de Pharmacie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Lauriane Segaux
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Esther Guery
- Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Gabin Ambime
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Marie-Thérèse Rabus
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Guy Perilliat
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Philippe David
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Elena Paillaud
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
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Urbankova J, Quiroz R, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention in postoperative patients. Phlebology 2016. [DOI: 10.1258/026835506778243031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
High incidence of venous thromboembolism (VTE) makes prophylaxis, screening and treatment extremely important. Both pharmacological and mechanical techniques can be used to reduce the risk of deep vein thrombosis (DVT). Mechanical methods have been studied much less intensively than pharmacological options. The principal mechanical methods of prophylaxis are graduated compression stockings and intemittent pneumatic compression devices. We conducted a meta-analysis of all randomized controlled trials to determine the effectiveness of intermittent pneumatic compression (IPC) devices in the preventon of DVT in post-surgical patients. The results of this analysis indicate that IPC devices reduced the risk of DVT by 60% when compared with patients with no mechanical or pharmacological prophylaxis. Contemporary randomized trials should be undertaken to test the utility of IPC in medcal patients as well as combined pharmacological plus IPC prophylaxis in both medical patients.
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Affiliation(s)
- J Urbankova
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - R Quiroz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - S Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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7
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Stark JE, Vesta KS. A Pharmacist-Initiated Method to Improve Venous Thromboembolic Prophylaxis Rates in Medically Ill Patients. J Pharm Pract 2016. [DOI: 10.1177/0897190006295398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism (VTE) is among the most preventable causes of hospital death; however, there is a significant underuse of VTE prophylaxis. The purpose of this study was to determine the impact of a pharmacist-initiated screening method on VTE prophylaxis rates. Clinical pharmacists practicing in an internal medicine teaching service at an academic medical center conducted a 6-month pilot project. Consecutive patients admitted to the service were screened for VTE and bleeding risk factors. Pharmacists made recommendations to the physicians in person, provided monthly educational presentations, and monitored patients daily until discharge to confirm continued appropriateness of recommendations. Of the 444 patients who were screened, 107 were identified to be candidates for VTE prophylaxis, and 21 of these patients also had bleeding risk factors. Appropriate use was significantly better after the screening intervention (37% before vs 85% after; P < .05). Moreover, inappropriate use in patients with bleeding risk factors was avoided by the screening intervention (29% before vs 0% after; P < .05). Clear improvements in VTE prophylaxis rates were observed. This pharmacist-initiated screening method presents unique opportunities for pharmacists.
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Affiliation(s)
- Jennifer E. Stark
- University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Oklahoma City
| | - Kimi S. Vesta
- University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Oklahoma City
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8
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Could a Coagulation Nurse Liaison Improve Compliance With Venous Thromboembolism Prophylaxis in Medical Patients? J Nurs Care Qual 2015; 31:E11-5. [PMID: 26488825 DOI: 10.1097/ncq.0000000000000154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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9
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Basey AJ, Krska J, Kennedy TD, Mackridge AJ. Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study. BMJ Open 2012; 2:e001668. [PMID: 23135540 PMCID: PMC3533008 DOI: 10.1136/bmjopen-2012-001668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 10/03/2012] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Implementing venous thromboembolism (VTE) risk assessment guidance on admission to hospital has proved difficult worldwide. In 2010, VTE risk assessment in English hospitals was linked to financial sanctions. This study investigated possible barriers and facilitators for VTE risk assessment in medical patients and evaluated the impact of local and national initiatives. SETTING Acute Medical Unit in one English National Health Service university teaching hospital. METHODS This was a mixed methods study; National Research Ethics Service approval was granted. Data were collected over four 1-week periods; November 2009 (1), January 2010 (2), April 2010 (3) and April 2011 (4). Case notes for all medical patients admitted during these periods were reviewed. Thirty-six staff were observed admitting 71 of these patients; 24 observed staff participated in a structured interview. RESULTS 876 case notes were reviewed. In total, 82.1% of patients had one or more VTE risk factors and 25.3% one or more bleeding risks. VTE risk assessment rose from a baseline of 6.9-19.6%, following local initiatives, and to 98.7% following financially sanctioned government targets. A similar increase in appropriate prescribing of prophylaxis was seen, but inappropriate prescribing also rose. No staff observed in period 1 conducted VTE risk assessment, risk-assessment forms were largely ignored or discarded during period 2; and electronic recording systems available during period 3 were not accessed. Few patients were asked any VTE-related questions in periods 1, 2 or 3. Interviewees' actual knowledge of VTE risk was not related to perceived knowledge level. Eight of the 24 staff interviewed were aware of national policies or guidance: none had seen them. Principal barriers identified to risk assessment were: involvement of multiple staff in individual admissions; interruptions; lack of policy awareness; time pressure and complexity of tools. CONCLUSIONS National financial sanctions appear effective in implementing guidance, where other local measures have failed.
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Affiliation(s)
- Avril Janette Basey
- Pharmacy Department, Royal Liverpool University Hospital, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Janet Krska
- Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Chatham, Kent, UK
| | - Tom D Kennedy
- Acute Medical Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Adam John Mackridge
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
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10
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Stark JE, Bird ML, Smith WJ, Vesta KS, Rathbun SW. Multidisciplinary Approach to Improve Venous Thromboembolism Risk Assessment and Prophylaxis Rates in Hospitalized Patients. J Pharm Technol 2012. [DOI: 10.1177/875512251202800407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Venous thromboembolism (VTE) is a preventable disease in hospitalized patients; however, VTE prophylaxis is underutilized. Effective strategies for the assessment of individual patients' VTE risk and the provision of VTE prophylaxis are needed. Objective: To evaluate the efficacy of a multidisciplinary intervention designed to improve VTE risk assessment and prophylaxis in at-risk hospitalized patients. Methods: The multidisciplinary intervention to improve VTE risk assessment and prophylaxis consisted of 3 strategies: a broad educational effort, nursing assessment, and pharmacist follow-up. Educational programs were delivered to nursing, pharmacy, and physician staff. Upon admission, all patients were assessed for VTE risk factors by nursing staff. Pharmacists reviewed reports of patients screened to have at least 1 VTE risk factor; for patients not prescribed VTE prophylaxis, pharmacists placed a progress note and VTE prophylaxis order form in the chart. If no prophylaxis was prescribed by the following day, the pharmacist contacted the physician with a verbal recommendation. The impact of this intervention was evaluated by comparing the proportion of patients assessed for VTE risk factors on admission and the proportion of VTE prophylaxis candidates who received prophylaxis, both before and after implementation. Results: A total of 310 patients were included during the 2-month study period. An increase in patients assessed for the presence of VTE risk factors was observed after the intervention (41% vs 87%, p < 0.001). Similarly, an increase in patients prescribed prophylaxis was observed after the intervention (36% vs 63%, p < 0.001). Conclusions: This multidisciplinary approach including education, nursing assessment, and pharmacist follow-up resulted in a significant increase in the rates of VTE risk assessment and prophylaxis.
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Affiliation(s)
- Jennifer E Stark
- JENNIFER E STARK PharmD BCPS, at time of writing, Assistant Professor, College of Pharmacy, University of Oklahoma, Oklahoma City; now, Clinical Pharmacy Specialist, Veterans Health Care System of the Ozarks, Fayetteville, AR
| | - Matthew L Bird
- MATTHEW L BIRD PharmD BCPS, Assistant Professor, Department of Pharmacy, Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
| | - Winter J Smith
- WINTER J SMITH PharmD BCPS, Associate Professor, Department of Pharmacy, Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
| | - Kimi S Vesta
- KIMI S VESTA PharmD BCPS, at time of writing, Associate Professor, College of Pharmacy, University of Oklahoma; now, Cardiovascular Regional Medical Liaison, Sanofi US Medical Affairs, Oklahoma City, OK
| | - Suman W Rathbun
- SUMAN W RATHBUN MD, Professor, Department of Medicine, Cardiovascular Section, College of Medicine, University of Oklahoma
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11
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Sharif-Kashani B, Shahabi P, Raeissi S, Behzadnia N, Shoaraka A, Shahrivari M, Saliminejad L, Pozhhan S, Hashemian MR, Masjedi MR, Bikdeli B. AssessMent of ProphylAxis for VenouS ThromboembolIsm in Hospitalized Patients. Clin Appl Thromb Hemost 2012; 18:462-8. [DOI: 10.1177/1076029611431955] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Venous thromboembolism (VTE) accounts for several cases of in-hospital mortality (over 100 000 deaths annually in the West). Despite the existence of effective prophylaxis guidelines for at-risk patients, the guidelines adherence is missing. Methods: We evaluated the thromboprophylaxis reception and appropriateness based on the eighth edition of the American College of Chest Physicians (ACCP) guidelines on VTE prophylaxis, among hospitalized patients of a World Health Organization (WHO)-collaborating teaching hospital in a 3-month period. Results: From the 904 evaluated cases, 481 entered the study. Appropriate decision on whether to prophylaxe or not, was made in 305 (63.40%), however, complete appropriateness (considering correct regimen type, dosing, and duration) was seen only in 229 patients (47.60%). The ACCP risk for VTE was the strongest predictor of thromboprophylaxis prescription (odds ratio [OR]: 2.62, 95% confidence interval [CI]: 1.35-5.05). Conclusions: Our thromboprophylaxis results were comparable to that of Western countries. Improved thromboprophylaxis appropriateness, which requires improving the physicians' thromboprophylaxis awareness and knowledge, could reduce the rate of in-hospital VTE and translate into better patient care.
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Affiliation(s)
- Babak Sharif-Kashani
- Tobacco Prevention and Control Research Center
- Lung Transplantation Research Center
| | | | | | | | | | | | | | | | | | - Mohammad-Reza Masjedi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih-Daneshvari Hospital, Shahid Beheshti University MC, Tehran, Iran
| | - Behnood Bikdeli
- Tobacco Prevention and Control Research Center
- Cardiovascular Research Center, Shahid Beheshti University MC, Tehran, Iran
- Center for Outcomes Research and Evaluation
- Section of Cardiovascular Medicine, Department of Internal medicine, Yale University School of Medicine, New Haven, CT, USA
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Mitchell JD, Collen JF, Petteys S, Holley AB. A simple reminder system improves venous thromboembolism prophylaxis rates and reduces thrombotic events for hospitalized patients1. J Thromb Haemost 2012; 10:236-43. [PMID: 22188121 DOI: 10.1111/j.1538-7836.2011.04599.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compliance with venous thromboembolism (VTE) prophylaxis is poor. OBJECTIVES We sought to determine whether a simple electronic reminder applicable to all hospitalized patients would increase prophylaxis rates and reduce VTE rates. METHODS An electronic reminder was added to the electronic medical record admission note used by all services in our hospital. Prophylaxis, VTE and bleeding rates before and after implementation were compared. Data were analyzed with sas version 9.1. RESULTS Among all adult medical and surgical patients admitted to our hospital during the time periods studied, 42.8% (1236/2888) before and 60.0% (1410/2350) after the reminder was added received appropriate prophylaxis as per American College of Chest Physicians (ACCP) guidelines (P < 0.001). The difference reached significance for both medical (51.0% vs. 68.9%; P < 0.001) and surgical (48.0% vs. 61.0%; P < 0.001) services. Fewer patients were diagnosed with VTE after our reminder was added (1.1% vs. 0.3%; P = 0.001), and there was a trend towards fewer bleeds (1.1% vs. 0.6%; P = 0.09). The presence of the reminder was an independent predictor for prophylaxis being given (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.70-2.18; P < 0.001), and was independently associated with a decreased risk for VTE (OR 0.30, 95% CI 0.14-0.64; P = 0.003) after adjustment for other VTE risk factors. CONCLUSION Adding an electronic reminder to the admission note improved prophylaxis rates and reduced VTE rates across services. The system is easily reproducible and applicable to other facilities. The improvement obtained was modest, so additional measures will probably be needed to optimize prophylaxis rates.
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Affiliation(s)
- J D Mitchell
- Department of Internal Medicine, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA
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13
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Lloyd NS, Douketis JD, Cheng J, Schünemann HJ, Cook DJ, Thabane L, Pai M, Spencer FA, Haynes RB. Barriers and potential solutions toward optimal prophylaxis against deep vein thrombosis for hospitalized medical patients: a survey of healthcare professionals. J Hosp Med 2012; 7:28-34. [PMID: 22038793 DOI: 10.1002/jhm.929] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 03/16/2011] [Accepted: 03/21/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Deep vein thrombosis (DVT) prophylaxis remains underused in hospitalized medical patients despite strong recommendations that at-risk patients should receive prophylaxis. To understand this gap between knowledge and practice, we surveyed clinicians' perceptions about the importance of DVT prophylaxis, barriers to guideline implementation, and interventions to optimize prophylaxis. METHODS Paper- and electronic mail-based surveys were sent to 1553 internists, nurses, pharmacists, and physiotherapists in Ontario, Canada. Responses were scored on 7-point Likert scales. An important barrier to optimal DVT prophylaxis was 1 with a mean score ≥5, and interventions with high potential success or feasibility were those with mean scores ≥5. RESULTS DVT prophylaxis was perceived as important by all clinician groups but this did not appear to translate into knowledge about underutilization of current DVT prophylaxis strategies. Physicians and pharmacists recognized the underuse of DVT prophylaxis in medical patients, while nurses and physiotherapists tended to perceive prophylaxis strategies as appropriate. Lack of clear indications and contraindications for prophylaxis and concerns about bleeding risks were perceived as important barriers. Preprinted orders were considered the most potentially successful and feasible way to optimize prophylaxis. CONCLUSIONS A considerable barrier to optimal DVT prophylaxis utilization may be that those healthcare providers best able to conduct a daily assessment of patients' need for prophylaxis underrecognize the problem that prophylaxis is underutilized in this population. Interventions to bridge the gap between knowledge and practice should consider preprinted orders outlining DVT risk factors, and educating front-line care providers prior to implementation of a top-down approach.
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Affiliation(s)
- Nancy S Lloyd
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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14
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Burton BL, Offurum AI, Grover B, Faddoul B, Gulati M, Seidl KL. Evaluating Transitions of Care of Hospitalized Medical Patients to Long-Term Care Facilities. Am J Med Qual 2011; 27:329-34. [DOI: 10.1177/1062860611425229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Brian Grover
- University of Maryland Medical Center, Baltimore, MD
| | - Badia Faddoul
- University of Maryland Medical Center, Baltimore, MD
| | - Mangla Gulati
- University of Maryland Medical Center, Baltimore, MD
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15
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Galbraith EM, Vautaw BM, Grzybowski M, Henke PK, Wakefield TW, Froehlich JB. Variation in physician deep vein thrombosis prophylaxis attitudes and practices at an academic tertiary care center. J Thromb Thrombolysis 2011; 30:419-25. [PMID: 20174856 DOI: 10.1007/s11239-010-0455-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) remains a major cause of in-hospital morbidity and mortality. Effective DVT prophylaxis is available but underutilized. We sought to describe physician understanding of DVT epidemiology and prophylaxis practices. METHODS All medical and surgical residents, and hospitalist attendings were invited to participate in an on-line survey. Physicians were queried about DVT epidemiology, risk factors, prophylaxis practices, and complications. Means and standard deviations were calculated for ordinal responses. χ² was used for dichotomous variables. RESULTS Of 281 doctors emailed, 69/160 (43%) medical residents, 26/72 (36%) surgical residents, and 21/49 (43%) hospitalist attendings participated. All three overestimated DVT incidence and morbidity. Surgical residents listed paralysis as high risk and minor surgery as a low/no risk factor. Medical residents thought heart failure and varicose veins were low/no risk for developing DVT. Regarding prophylaxis, surgical residents did not identify ambulation as a prophylactic measure, and were more likely to use SCDs, compression stockings, and enoxaparin, while medical residents and hospitalist attendings prescribed unfractionated heparin most frequently. Medical residents reported that they would hold anticoagulants for comorbidities most frequently, but all 3 groups agreed that anticoagulant prophylaxis would not significantly increase bleeding risks. CONCLUSIONS Perceptions of DVT risk factors and prophylaxis practices vary by both physician specialty and attending/resident status. Prophylaxis practice differences may result from these perceptions.
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Affiliation(s)
- Erin M Galbraith
- Division of Cardiology, Emory University Hospitals, 1639 Pierce Drive, Suite 319 WMB, Atlanta, GA 30322, USA.
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16
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Bernier MC, Desjardins K, Filiatrault J, Sauriol MA, Martineau J, Gilbert E, Caron S, Lalonde L. Implementation and evaluation of a pharmacy-led thromboprophylaxis campaign in a community hospital. J Thromb Thrombolysis 2011; 32:431-8. [PMID: 21769596 DOI: 10.1007/s11239-011-0614-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start). J Thromb Thrombolysis 2010; 29:326-39. [PMID: 19548071 PMCID: PMC2837191 DOI: 10.1007/s11239-009-0361-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The 7th conference of the American College of Chest Physicians (ACCP7) provides recommendations on the type, dose, and duration of thromboprophylaxis in hospitalized patients at risk of venous thromboembolism (VTE), but the extent to which hospitals follow these criteria has not been well studied. Discharge and billing records for patients admitted to any of 16 acute-care hospitals from January 2005 to December 2006 were obtained. Patients 18 years or older who had an inpatient stay ≥2 days and no apparent contraindications for thromboprophylaxis were grouped into the categories of critical care, surgery and medically ill before being assessed for additional VTE risk factors based on the diagnostic criteria outlined in ACCP7. For patients at risk, the recommended type (mechanical or pharmacologic), dose, and duration of thromboprophylaxis was identified based on the guidelines and compared to the regimen actually received, if any. Among the 258,556 hospitalized patients, 68,278 (26.4%) were determined to be at risk of VTE without apparent contraindications for thromboprophylaxis. The proportions of patients who received the appropriate type, dose, and duration of thromboprophylaxis were 10.5, 9.8, and 17.9% for critical care, medical, and surgical patients, respectively. Of those at risk, 36.8% received no thromboprophylaxis and an additional 50.2% received thromboprophylaxis deemed inappropriate for one or more reasons. The implementation of ACCP7 guidelines for type, dosage, and duration of thromboprophylaxis is low in patients at risk of VTE. There is a need for physicians and health systems to improve awareness and implementation of recommended thromboprophylaxis.
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18
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Baser O, Supina D, Sengupta N, Wang L, Kwong L. Impact of postoperative venous thromboembolism on Medicare recipients undergoing total hip replacement or total knee replacement surgery. Am J Health Syst Pharm 2010; 67:1438-45. [DOI: 10.2146/ajhp090572] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Onur Baser
- STATinMED Research, Ann Arbor, MI, and University of Michigan, Ann Arbor
| | | | - Nishan Sengupta
- Health Outcomes, Ortho-McNeil Janssen Scientific Affairs, Johnson and Johnson Pharmaceutical Services, Raritan, NJ
| | | | - Louis Kwong
- Department of Orthopaedic Surgery, Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, and Director, Orthopaedic Research Program, School of Medicine, UCLA, Torrance
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Dávid M, Losonczy H, Udvardy M, Boda Z, Blaskó G, Tar A, Pfliegler G. [Questionnaire for assessing the risk of venous thromboembolism in hospitalized surgical and non-surgical patients in the 4th Hungarian antithrombotic guideline entitled "Risk reduction and treatment of venous thromboembolism"]. Orv Hetil 2010; 151:1365-74. [PMID: 20705551 DOI: 10.1556/oh.2010.28944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A large proportion of hospitalized surgical and medical patients are at risk for venous thromboembolism. Depending on the type of surgical intervention, venous thrombosis develops in 15-60% of surgical patients without prophylaxis. Although venous thromboembolism is most often considered to be associated with recent surgery or trauma, 50 to 70% of symptomatic thromboembolic events and 70 to 80% of fatal pulmonary embolisms occur in nonsurgical patients. International and national registries show that the majority of at-risk surgical patients actually received the appropriate thromboembolic prophylaxis. However, despite of international and national recommendations, prophylaxis was not provided for a large proportion of at-risk medical patients. The rate of medical patients receiving prophylaxis should be increased, and appropriate thrombosis prophylaxis should be offered to at-risk medical patients. The thrombosis risk assessment is an important tool to identify patients at increased risk for venous thromboembolism, to simplify decision making on prophylaxis administration, and to improve the adherence to guidelines. When the risk is recognized, if there is no contraindication, prophylaxis should be ordered. The 4th Hungarian Antithrombotic Guideline entitled "Risk reduction and treatment of thromboembolism" calls attention to the importance of risk assessment and for the first time it includes and recommends risk assessment models for hospitalized surgical and medical patients. The risk assessment models are presented and the evidence based data for the different risk factors included in these models are reviewed.
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Affiliation(s)
- Marianna Dávid
- Pécsi Tudományegyetem, Altalános Orvostudományi Kar I. Belgyógyászati Klinika, Pécs.
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20
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Sharif-Kashani B, Raeissi S, Bikdeli B, Shahabi P, Behzadnia N, Saliminejad L, Samiei-Nejad M, Nasiri F, Khayyami M, Forootan B, Pozhan S, Masjedi MR. Sticker reminders improve thromboprophylaxis appropriateness in hospitalized patients. Thromb Res 2010; 126:211-6. [PMID: 20667584 DOI: 10.1016/j.thromres.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 04/20/2010] [Accepted: 05/13/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major health problem. Even though effective thromboprophylaxis measures exist to prevent VTE, close adherence to guidelines is missing. We assessed the effects of pasting VTE prophylaxis sticker reminders, on the appropriateness of thromboprophylaxis and prophylaxis underutilization. METHODS Thromboprophylaxis reception was sought prospectively in two time points before and two time points after pasting sticker reminders in hospitalized patients of Masih Daneshvari Medical Center, Tehran, Iran. Thromboprophylaxis reception appropriateness was evaluated by the eighth American College of Chest Physicians (ACCP) guidelines on antithrombotic and thrombolytic therapy. Co-morbidities and conditions considered to affect the risk of venous thromboembolism were also recorded. RESULTS Prophylaxis reception and appropriateness were studied in 298 patients before and 306 patients after the intervention. Based on the ACCP guidelines, overall thromboprophylaxis appropriateness was improved after the intervention (70.4% before, and 78.1% after the intervention, P=0.03). Prophylaxis underutilization, and prophylaxis initiation delay in those who needed thromboprophylaxis, were also reduced (P=0.03, and P=0.011 respectively). The intervention did not result in an increased rate of overprophylaxis (P=0.45). CONCLUSION Sticker reminders could be safely and effectively incorporated into strategies to improve VTE prophylaxis and prophylaxis appropriateness, particularly in healthcare settings where electronic alert systems are not available.
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Affiliation(s)
- Babak Sharif-Kashani
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University MC, Tehran, Iran
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21
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Khalili H, Dashti-Khavidaki S, Talasaz AH, Mahmoudi L, Eslami K, Tabeefar H. Is deep vein thrombosis prophylaxis appropriate in the medical wards? A clinical pharmacists’ intervention study. ACTA ACUST UNITED AC 2010; 32:594-600. [DOI: 10.1007/s11096-010-9412-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 06/28/2010] [Indexed: 11/25/2022]
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Emed JD, Morrison DR, Rosiers LD, Kahn SR. Definition of immobility in studies of thromboprophylaxis in hospitalized medical patients: A systematic review. JOURNAL OF VASCULAR NURSING 2010; 28:54-66. [DOI: 10.1016/j.jvn.2009.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 12/20/2009] [Accepted: 12/21/2009] [Indexed: 01/30/2023]
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Development of national performance measures on the prevention and treatment of venous thromboembolism. J Thromb Thrombolysis 2009; 29:148-54. [DOI: 10.1007/s11239-009-0407-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Venous thromboembolism, a condition that includes deep vein thrombosis and pulmonary embolism, is a significant medical problem that affects more than 1 million patients each year. In addition to the immense impact of venous thromboembolism on morbidity and mortality, the economic burden of the disease is considerable, costing the health care system in the United States more than $1.5 billion/year. The cost of managing an initial episode of deep vein thrombosis is estimated at $7712-10,804, and for an initial pulmonary embolism event $9566-16,644. Management of acute venous thromboembolism in patients with cancer costs more than $20,000. Although much of the costs of venous thromboembolism are associated with managing the acute event, there are also significant costs associated with its long-term complications such as recurrent venous thromboembolism, postthrombotic syndrome, and pulmonary hypertension. Data from numerous robust clinical trials have demonstrated that with appropriate prophylaxis, many of these venous thromboembolism events can be prevented in both surgical and medical patients. Even though the strong evidence supporting venous thromboembolism prophylaxis spans several decades, a number of large American and global registries have documented very poor use of appropriate venous thromboprophylaxis. Because of increasing regulatory requirements, hospitals nationwide are developing necessary documentation of appropriate venous thromboembolism prophylaxis programs for both surgical and medical patients. Hospitals and clinicians must have a firm understanding of not only the clinical impact but also the economic impact of failing to use appropriate prophylaxis and of the cost-effectiveness of different venous thromboprophylaxis methods.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6045, USA.
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Páramo JA, Lecumberri R. Enfermedad tromboembólica venosa: una llamada urgente a la acción. Med Clin (Barc) 2009; 133:547-51. [DOI: 10.1016/j.medcli.2009.02.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 02/26/2009] [Indexed: 11/30/2022]
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Venous thromboembolism prophylaxis in hospitalized patients with pneumonia: a prospective survey. Wien Klin Wochenschr 2009; 121:318-23. [PMID: 19562294 DOI: 10.1007/s00508-009-1173-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Guidelines for prevention of venous thromboembolism recognize pneumonia and changes in respiratory status as risk factors. There is little information on the preventive use of low-molecular-weight heparin (LMWH) in hospitalized patients with pneumonia. METHODS We prospectively screened 1067 admissions to our hospital for preventive use of LMWH according to the American College of Chest Physicians (ACCP) guidelines. The analysis included 168 patients with pneumonia (age 74 +/- 16 years, 56% men). The primary and secondary outcomes were treatment with LMWH in eligible patients and LMWH use according to guidelines (daily dose, duration of treatment). RESULTS LMWH use was indicated in 126 (75%) patients and 119 (94%) were actually treated. In 41% of patients treatment was according to the ACCP guidelines. The dose and duration of LMWH treatment were appropriate in 61% and 66% of patients, respectively. Non-use of LMWHs was not associated with clinical and demographic characteristics. Adverse effects included bleeding (N = 7) and thrombocytopenia (N = 2) but were not associated with fatality. Prolonged treatment with LMWH was associated with adverse effects (P < 0.05). CONCLUSIONS Implementation of LMWH prophylaxis for venous thromboembolism in hospitalized patients with pneumonia reached 94%. Adherence to ACCP guidelines was complete in 41% of patients. Prolonged treatment with LMWH was associated with non-fatal adverse effects, which calls for timely withdrawal of LMWH once no longer indicated.
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Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676]. Med Care 2009; 47:642-50. [PMID: 19433997 DOI: 10.1097/mlr.0b013e3181926032] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medical inpatients are at risk for suboptimal health outcomes from adverse drug events and under-use of evidence-based therapies. We sought to determine whether collaborative care including a team-based clinical pharmacist improves the quality of prescribed drug therapy and reduces hospital readmission. METHODS Multicenter, quasi-randomized, controlled clinical trial. Consecutive patients admitted to 2 internal and 2 family medicine teams in 3 teaching hospitals between January 30, 2006 and February 2, 2007 were included. Team care patients received proactive clinical pharmacist services (medication history, patient-care round participation, resolution of drug-related issues, and discharge counseling). Usual care patients received traditional reactive clinical pharmacist services. The primary outcome was the overall quality score measured retrospectively by a blinded chart reviewer using 20 indicators targeting 5 conditions. Secondary outcomes included 3- and 6-month readmission. RESULTS A total of 452 patients (220 team care, 231 usual care, mean age: 74 years, 46% male) met eligibility criteria. Team care patients were more likely than usual care patients to receive care specified by the indicators overall (56.4% vs. 45.3%; adjusted mean difference: 10.4%; 95% confidence interval [CI]: 4.9%, 15.7%) and for each targeted disease state except for heart failure. Team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%; adjusted OR: 0.63; 95% CI: 0.42, 0.94) but not at 6 months (50.7% vs. 56.3%; adjusted OR; 0.78; 95% CI: 0.53, 1.15). CONCLUSIONS In patients admitted to internal and family medicine teams, team-based care including a clinical pharmacist, improved the overall quality of medication use and reduced rates of readmission.
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Cook D, Tkaczyk A, Lutz K, McMullin J, Haynes RB, Douketis J. Thromboprophylaxis for hospitalized medical patients: a multicenter qualitative study. J Hosp Med 2009; 4:269-75. [PMID: 19504488 DOI: 10.1002/jhm.461] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Observational studies have documented that medical patients infrequently receive venous thromboembolism (VTE) prevention. OBJECTIVE To understand the barriers to, and facilitators of, optimal thromboprophylaxis. PATIENTS Hospitalized medical patients. DESIGN We conducted in-depth interviews with 15 nurses, 6 pharmacists, 12 physicians with both clinical and managerial experience, and 3 hospital administrators. SETTING One university-affiliated and 2 community hospitals. INTERVENTION Interviews were audiotaped and transcribed verbatim. Transcripts were reviewed and interpreted independently in duplicate. MEASUREMENT Analysis was conducted using grounded theory. RESULTS Physicians and pharmacists affirmed that evidence supporting heparin is strong and understood. Clinicians, particularly nurses, reported that mobilization was important, but were uncertain about how much mobilization was enough. Participants believed that depending on individual physicians for VTE prevention is insufficient. The central finding was that multidisciplinary care was also perceived as a barrier to effective VTE prevention because it can lead to unclear accountability by role confusion. Participants believed that a comprehensive, systems approach was necessary. Suggestions included screening and risk-stratifying all patients, preprinted orders at hospital admission that are regularly reevaluated, and audit and feedback programs. Patient or family-mediated reminders, and administrative interventions, such as hiring more physiotherapists and profiling thromboprophylaxis in hospital accreditation, were also endorsed. CONCLUSIONS Universal consideration of thromboprophylaxis finds common ground in multidisciplinary care. However, results of this qualitative study challenge the conviction that either individual physician efforts or multidisciplinary care are sufficient for optimal prevention. To ensure exemplary medical thromboprophylaxis, clinicians regarded coordinated, systemwide processes, aimed at patients, providers, and administrators as essential.
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Affiliation(s)
- Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Le Sage S, McGee M, Emed JD. Knowledge of Venous Thromboembolism (VTE) prevention among hospitalized patients. JOURNAL OF VASCULAR NURSING 2008; 26:109-17. [DOI: 10.1016/j.jvn.2008.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 09/28/2008] [Accepted: 09/29/2008] [Indexed: 10/21/2022]
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Risk factors for venous thromboembolism in the elderly: results of the master registry. Blood Coagul Fibrinolysis 2008; 19:663-7. [DOI: 10.1097/mbc.0b013e3283079e58] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Garrido Martínez M, Aguayo Canela M, Herrera Carranza J, Chaparro Moreno I, Ynfante Ferrus M, de la Rosa Báez J, Fernández Lisón L. Adecuación de la utilización de heparinas de bajo peso molecular en la prevención de la enfermedad tromboembólica venosa. FARMACIA HOSPITALARIA 2008. [DOI: 10.1016/s1130-6343(08)75945-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Acute venous disease: Venous thrombosis and venous trauma. J Vasc Surg 2007; 46 Suppl S:25S-53S. [DOI: 10.1016/j.jvs.2007.08.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2006] [Revised: 08/15/2007] [Accepted: 08/19/2007] [Indexed: 10/22/2022]
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Masroujeh R, Shamseddeen W, Isma'eel H, Otrock ZK, Khalil IM, Taher A. Underutilization of venous thromboemoblism prophylaxis in medical patients in a tertiary care center. J Thromb Thrombolysis 2007; 26:138-41. [PMID: 17701104 DOI: 10.1007/s11239-007-0084-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Accepted: 07/30/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND New recommendations concerning the use of prophylactic anticoagulation for medically ill patients have been in use for some time now. This study aims at assessing how much house-staff in a tertiary care setting are implementing these new recommendations in the hope that through quantitative analysis of the deficiency we would be able to identify areas of weakness. METHODS About 250 patients were randomly selected from all patients admitted to the American University of Beirut Medical Center (AUBMC) during the year 2005 and stayed more than 48 h. The risk factor profiles, contraindications to thromboprophylaxis, if present, and whether these patients received the appropriate VTE pharmacologic prophylaxis during their stay in hospital were recorded. RESULTS About 139 patients were found to have two or more risk factors, with no absolute contraindications. About 37 patients (26.6%) received VTE prophylaxis. Upon reviewing the risk factors profile, the majority of patients (71.3%) were found to have 2-4 risk factors. Among risk factors studied, age > 40 years, admission to ICU, prior VTE, chronic lung disease, infection, respiratory failure, and central venous catheter were significantly associated with receiving prophylaxis. CONCLUSIONS VTE prophylaxis is underutilized at AUBMC, a tertiary care teaching hospital in the Middle East. Critical care patients were being acceptably anti-coagulated, whereas cancer patients are doing the worst.
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Affiliation(s)
- Ramy Masroujeh
- Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon
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Burleigh E, Wang C, Foster D, Heller S, Dunn D, Safavi K, Griffin B, Smith J. Thromboprophylaxis in medically ill patients at risk for venous thromboembolism. Am J Health Syst Pharm 2007; 63:S23-9. [PMID: 17032931 DOI: 10.2146/ajhp060390] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE According to guidelines from the American College of Chest Physicians, low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) should be prescribed to medical (nonsurgical) patients at high risk of venous thromboembolism. Thromboprophylaxis and mortality rates were determined in medical inpatients with indications for thromboprophylaxis. Cost differences between patient groups were investigated and are discussed. SUMMARY Using Solucient's ACTracker Inpatient Database, medical discharges between January 2001 and December 2004 were extracted and patients who had indications for thromboprophylaxis (acute myocardial infarction, ischemic stroke, cancer, heart failure, or severe lung disease) were identified. Patients < 40 years or with deep-vein thrombosis or pulmonary embolism, active peptic ulcer, malignant hypertension, blood disease, HIV infection, or intubation of gastrointestinal or respiratory tract were excluded. Rates of thromboprophylaxis and mortality were compared between groups. Mean total drug costs and hospital costs per patient discharge were compared between patient groups. Of 12,887,080 medical discharges extracted from 330 hospitals, there were 2,367,362 patients with indications for thromboprophylaxis. Patients were subdivided on the basis of whether they received thromboprophylaxis (n = 717,850) or not (n = 1,649,512). The thromboprophylaxis rate was low, despite increasing from 26% to 33% over the study period. Patients receiving thromboprophylaxis had significantly lower risk-adjusted mortality rates than those who did not (p < 0.001), except those with ischemic stroke. The mean total drug cost per patient receiving LMWH and UFH ($791 and $569, respectively) was higher than for patients not receiving thromboprophylaxis ($372) (p < 0.001). The mean total hospital cost per patient receiving UFH ($7615) was higher than for LMWH ($6866, p < 0.001). CONCLUSION The thromboprophylaxis rate among medical patients was low, with no significant improvement between 2001 and 2004. Thromboprophylaxis can impact patient mortality rates. Economic evaluation revealed that the use of LMWH for thromboprophylaxis in at-risk medical patients was associated with higher total drug costs but lower total hospital costs than UFH. Efforts should be made to increase clinicians' awareness of clinical guidelines.
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Dorfman M, Chan SB, Maslowski C. Hospital-acquired venous thromboembolism and prophylaxis in an integrated hospital delivery system. J Clin Pharm Ther 2006; 31:455-9. [PMID: 16958823 DOI: 10.1111/j.1365-2710.2006.00764.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Without prophylaxis, hospital-acquired deep vein thrombosis (DVT) is approximately 10-40% among medical or general surgical patients and thromboprophylaxis for high-risk patients is currently recommended. This study analyse the risk factors associated with patients who developed a hospital-acquired venous thromboembolism (VTE) and what prior prophylaxis, if any, were given to these patients. METHODS We identified 1 year of secondary VTE from seven metropolitan hospitals. A random sample was selected and reviewed retrospectively. Data abstracted included age, gender, VTE risk factors, surgeries, VTE prophylaxis, and anticoagulant dosing. Data analysis consisted of descriptive statistics. RESULTS A total of 118 patients with mean age 72.1 years (range 23-96) and 55.1% female. There were 60.2% DVT followed by 36.4% pulmonary embolism (PE); 7.6% had both DVT and PE diagnosed. About 73.7% of the study patients had two or more VTE risk factors. Five (4.2%) patients with hospital-acquired VTE had no risk factors. Overall, 88.5% of patients with risk factors received adequate VTE prophylaxis; 20.3% received heparin or enoxaparin, 56.6% received warfarin, and 11.5% received mechanical prophylaxis secondary to drug contraindications. Nine (8.0%) patients with risk factors and no contraindications, did not received any prophylaxis while four patients (3.5%) received inadequate prophylaxis. All-cause mortality was 13.6% (16/118). CONCLUSION Less than 5% of hospital-acquired VTE occurred in patients with no risk factors while 74% occurred in patients with two or more risk factors. In this seven-hospital study, 11.5% of hospital-acquired VTE with prior risk factors did not receive adequate prophylaxis. Educational in-services on the new CHEST guidelines should be provided within the hospitals to increase adherence to prophylaxis guidelines.
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Affiliation(s)
- M Dorfman
- Resurrection Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, IL 60631, USA.
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Peterman CM, Kolansky DM, Spinler SA. Prophylaxis against venous thromboembolism in acutely ill medical patients: an observational study. Pharmacotherapy 2006; 26:1086-90. [PMID: 16863485 DOI: 10.1592/phco.26.8.1086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To determine the risk factors for venous thromboembolism (VTE) and the rates of prophylactic measures used in acutely ill medical patients. DESIGN Prospective observational study. SETTING Academic tertiary care medical center. PATIENTS One hundred seventy-nine patients admitted to three general medical units over 30 consecutive days and hospitalized for at least 3 days. MEASUREMENTS AND MAIN RESULTS On concurrent review of the patients' medical records, 138 (77.1%) of 179 patients received one or more forms of VTE prophylaxis during their hospital stay. Of 41 (22.9%) patients receiving no VTE prophylaxis, 22 (53.7%) had and 19 (46.3%, or 10.6% of the total population) did not have a documented contraindication to anticoagulation. One hundred ten patients (61.5%) had three or more documented VTE risk factors for VTE. The most common prophylaxis was unfractionated heparin 5000 U injected subcutaneously twice/day. Therapeutic anticoagulation was given to 51 patients (28.5%) at some time during their hospitalization for indications other than VTE treatment. Two developed symptomatic VTE (1.1%) while hospitalized. Four patients (2.2%) receiving anticoagulants had adverse outcomes. One patient had minor bleeding, and one developed heparin-induced thrombocytopenia without thrombosis. CONCLUSION Rates of VTE prophylaxis were higher than previously reported rates, although no formalized guidelines, standardized order sets, alerting programs, training, or risk-stratification tools were used during the study period. Rates of adverse events were low.
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Affiliation(s)
- Carla M Peterman
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
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Salonia A, Suardi N, Crescenti A, Colombo R, Rigatti P, Montorsi F. General versus spinal anesthesia with different forms of sedation in patients undergoing radical retropubic prostatectomy: Results of a prospective, randomized study. Int J Urol 2006; 13:1185-90. [PMID: 16984550 DOI: 10.1111/j.1442-2042.2006.01524.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To assess the impact of spinal anesthesia (SpA) combined with three different forms of conscious sedation on intraoperative and postoperative outcome in patients undergoing radical retropubic prostatectomy (RRP) for organ confined prostate cancer (pCa). METHODS A total of 121 consecutive patients with pCa undergoing RRP were randomized into four groups. They were randomized as follows: group 1 (general anesthesia: 34 patients), group 2 (lumbar 2 to lumbar 3 interspace SpA with diazepam as sedative agent: 28), group 3 (SpA with propofol: 30), and group 4 (SpA with midazolam: 29). Intraoperative and perioperative parameters were collected. RESULTS The present study showed that muscle relaxation throughout RRP was not different in the four groups; bleeding was significantly (P = 0.04) lower with SpA, regardless of the form of sedation. Group 3 patients reported the best postoperative oxygen saturation percentage by pulse oximetry and sedation score (P = 0.02; d.f. = 3 and P < 0.0001; d.f. = 3, respectively), the shortest waiting time in the postoperative holding area (P < 0.001; d.f. = 3), the lowest pain on postoperative day 1 (P = 0.0004; d.f. = 3), and the highest frequency of first flatus passage (P = 0.0001; d.f. = 3). A higher number of group 4 patients were able to carry out unassisted ambulation (P < 0.0001; d.f. = 3). CONCLUSIONS Conscious sedation coupled with SpA is a safe, reliable and effective procedure for patients undergoing RRP. The use of propofol as sedative agent offers several advantages both over other types of conscious sedation and general anesthesia.
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Affiliation(s)
- Andrea Salonia
- Department of Urology, University Vita--Salute San Raffaele, Scientific Institute H. San Raffaele, Milan, Italy.
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Deheinzelin D, Braga AL, Martins LC, Martins MA, Hernandez A, Yoshida WB, Maffei F, Monachini M, Calderaro D, Campos W, Sguizzatto GT, Caramelli B. Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil. J Thromb Haemost 2006; 4:1266-70. [PMID: 16706970 DOI: 10.1111/j.1538-7836.2006.01981.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Although effective strategies for the prevention of venous thromboembolism (VTE) are widely available, a significant number of patients still develop VTE because appropriate thromboprophylaxis is not correctly prescribed. We conducted this study to estimate the risk profile for VTE and the employment of adequate thromboprophylaxis procedures in patients admitted to hospitals in the state of São Paulo, Brazil. METHODS Four hospitals were included in this study. Data on risk factors for VTE and prescription of pharmacological and non-pharmacological thromboprophylaxis were collected from 1454 randomly chosen patients (589 surgical and 865 clinical). Case report forms were filled according to medical and nursing records. Physicians were unaware of the survey. Three risk assessment models were used: American College of Chest Physicians (ACCP) Guidelines, Caprini score, and the International Union of Angiololy Consensus Statement (IUAS). The ACCP score classifies VTE risk in surgical patients and the others classify VTE risk in surgical and clinical patients. Contingency tables were built presenting the joined distribution of the risk score and the prescription of any pharmacological and non-pharmacological thromboprophylaxis (yes or no). RESULTS According to the Caprini score, 29% of the patients with the highest risk for VTE were not prescribed any thromboprophylaxis. Considering the patients under moderate, high or highest risk who should be receiving prophylaxis, 37% and 29% were not prescribed thromboprophylaxis according to ACCP (surgical patients) and IUAS risk scores, respectively. In contrast, 27% and 42% of the patients at low risk of VTE, according to Caprini and IUAS scores, respectively, had thromboprophylaxis prescribed. CONCLUSION Despite the existence of several guidelines, this study demonstrates that adequate thromboprophylaxis is not correctly prescribed: high-risk patients are under-treated and low-risk patients are over-treated. This condition must be changed to insure that patients receive adequate treatment for the prevention of thromboembolism.
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Chopard P, Spirk D, Bounameaux H. Identifying acutely ill medical patients requiring thromboprophylaxis. J Thromb Haemost 2006; 4:915-6. [PMID: 16634771 DOI: 10.1111/j.1538-7836.2006.01818.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kahn SR, Panju A, Geerts W, Pineo GF, Desjardins L, Turpie AGG, Glezer S, Thabane L, Sebaldt RJ. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2006; 119:145-55. [PMID: 16516275 DOI: 10.1016/j.thromres.2006.01.011] [Citation(s) in RCA: 218] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Revised: 01/05/2006] [Accepted: 01/12/2006] [Indexed: 01/08/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis in acutely ill medical patients has been shown to be safe and effective. Underutilization of this patient safety practice may result in avoidable mortality and morbidity. OBJECTIVES We aimed to determine the proportion of hospitalized, acutely ill medical patients across Canada who were eligible to receive thromboprophylaxis and to evaluate the frequency, determinants and appropriateness of its use. PATIENTS/METHODS CURVE is a national, multicenter chart audit of 29 Canadian hospitals. Data were collected on consecutive patients admitted to hospital for an acute medical illness during a defined 3-week study period. Information on demographic and clinical characteristics, risk factors for VTE and bleeding and use of VTE prophylaxis were recorded. The indications for and appropriateness of VTE prophylaxis were assessed using pre-specified criteria based on international consensus guidelines. Multivariable analyses were performed to identify determinants of prophylaxis use. RESULTS Of the 4124 medical admissions screened over the study period, 1894 patients (46%) were eligible for study inclusion. The most common specified admitting diagnoses were severe infection (28%), COPD exacerbation or respiratory failure (12%), malignancy (9%) and congestive heart failure (8%). Thromboprophylaxis was indicated in 1702 (90%) study patients. Overall, some form of prophylaxis was administered to 23% of all patients. However, only 16% received appropriate thromboprophylaxis. Factors independently associated with greater use of prophylaxis included internist (vs. other specialty) as attending physician (OR 1.33, 95% confidence interval (CI) [1.03, 1.71]), university-associated (vs. community) hospital (OR 1.46, 95% CI [1.03, 2.07]), immobilization (per day) (OR 1.60, 95% CI [1.45, 1.77]), presence of >or=1 VTE risk factors (OR=1.78, 95% CI [1.35, 2.34]) and duration of hospitalization (per day of stay) (OR 1.05, 95% CI [1.03, 1.07]), however, use of prophylaxis was unacceptably low in all groups. Patients with cancer had a significantly reduced likelihood of receiving prophylaxis (OR=0.40, 95% CI [0.24, 0.68]). Presence of risk factors for bleeding did not influence the use or choice of prophylaxis. CONCLUSION Most patients hospitalized for medical illness had indications for thromboprophylaxis, yet only 16% received appropriate prophylaxis. Efforts should be made to elucidate the reasons that underlie the very low rate of thromboprophylaxis in medical patients and to develop and test strategies to improve implementation of this patient safety practice.
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Affiliation(s)
- Susan R Kahn
- Department of Medicine, McGill University, SMBD Jewish General Hospital, Canada.
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Lederle FA, Sacks JM, Fiore L, Landefeld CS, Steinberg N, Peters RW, Eid AA, Sebastian J, Stasek JE, Fye CL. The prophylaxis of medical patients for thromboembolism pilot study. Am J Med 2006; 119:54-9. [PMID: 16431185 DOI: 10.1016/j.amjmed.2005.03.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Revised: 03/17/2005] [Accepted: 03/17/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE We assessed the feasibility of a large randomized trial intended to determine whether low-dose heparin prophylaxis given throughout hospitalization reduces mortality and morbidity in general medical patients. SUBJECTS AND METHODS Hospitalized general medical patients aged more than 60 years at 5 Department of Veterans Affairs (VA) medical centers were randomized to receive enoxaparin 40 mg or identical placebo, given daily by subcutaneous injection until hospital discharge. Outcomes included total mortality at 90 days (the primary outcome) and 1 year, and occurrence in the VA hospital within 90 days of symptomatic deep venous thrombosis, pulmonary embolism, and major bleeding. RESULTS Only 7.6% of hospitalized patients aged more than 60 years were eligible for the study, although a chart review had predicted 25%. The principal exclusions were prior indication for anticoagulation, anticipated need for anticoagulation, contraindication to heparin, expected hospitalization less than 3 days, and "supportive/palliative care only" status. We randomized 140 patients into each group, 28% of target recruitment. The groups were well matched by age and comorbidities. Death occurred in 13 patients receiving enoxaparin and 14 patients receiving placebo at 90 days (relative risk 0.93, 95% confidence interval 0.26-1.59), and in 36 and 32 patients, respectively, at 1 year (relative risk 1.13, 95% confidence interval 0.66-1.60). Clinical thromboembolic events occurred in 5 patients receiving enoxaparin and 8 patients receiving placebo, and major bleeding occurred in 2 and 5 patients, respectively. CONCLUSIONS The pilot study indicated that the full study was not feasible. The decision to use prophylaxis pertains to only a small proportion of general medical patients hospitalized at VA medical centers, and this proportion is overestimated by chart review. The effect of low-dose heparin prophylaxis on clinical outcomes in hospitalized general medical patients remains uncertain.
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Affiliation(s)
- Frank A Lederle
- Department of Medicine, Minneapolis Center for Epidemiological and Clinical Research, Veterans Affairs Medical Center, Minneapolis, Minn 55417, USA.
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Rashid ST, Thursz MR, Razvi NA, Voller R, Orchard T, Rashid ST, Shlebak AA. Venous thromboprophylaxis in UK medical inpatients. J R Soc Med 2005. [PMID: 16260800 DOI: 10.1258/jrsm.98.11.507] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the data in changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice. 1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate risk of developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis-4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grand rounds, showed a significant increase to 31% inpatients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However,the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59). We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increase the overall proportion of patients receiving it. We therefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deep venous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
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Affiliation(s)
- S T Rashid
- Department of Medicine, St James University Hospital NHS trust, Beckett Street, Leeds, UK
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Rashid ST, Thursz MR, Razvi NA, Voller R, Orchard T, Rashid ST, Shlebak AA. Venous thromboprophylaxis in UK medical inpatients. J R Soc Med 2005; 98:507-12. [PMID: 16260800 PMCID: PMC1275999 DOI: 10.1177/014107680509801112] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the data in changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice. 1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate risk of developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis-4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grand rounds, showed a significant increase to 31% inpatients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However,the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59). We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increase the overall proportion of patients receiving it. We therefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deep venous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
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Affiliation(s)
- S T Rashid
- Department of Medicine, St James University Hospital NHS trust, Beckett Street, Leeds, UK
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Perrin K, Robinson P, Beasley R. Venous Thromboembolism in Medical Inpatients–-the Silent Epidemic of Neglect. Med Chir Trans 2005; 98:484-5. [PMID: 16260792 PMCID: PMC1275991 DOI: 10.1177/014107680509801103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Chopard P, Dörffler-Melly J, Hess U, Wuillemin WA, Hayoz D, Gallino A, Bachli EB, Canova CR, Isenegger J, Rubino R, Bounameaux H. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med 2005; 257:352-7. [PMID: 15788005 DOI: 10.1111/j.1365-2796.2005.01455.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM OF THE STUDY To examine the frequency and adequacy of thromboprophylaxis in acutely ill medical patients hospitalized in eight Swiss medical hospitals. METHODS A cross-sectional study of 1372 patients from eight Swiss hospitals was carried out. After exclusion of patients (275) given therapeutic anticoagulation, 1097 patients were audited. The adequacy of thromboprophylaxis was assessed by comparison with predefined explicit criteria. RESULTS Of 1097 patients, 542 (49.4%) received thromboprophylaxis. According to the explicit criteria, 644 (58.7%) should have been on prophylaxis (P < 0.001, when compared with the rate observed). The rate of prevention differed widely between hospitals (from 29.4 to 88.6%) with no difference between teaching and nonteaching hospitals. According to the explicit criteria, a substantial proportion (44.9%) of the patients who should have been treated were not. Conversely, 41.3% of the patients were unnecessarily treated. CONCLUSIONS Even though the appropriateness of the explicit criteria used could be challenged, our data suggest that the current practice is associated with important uncertainty leading to both overuse and underuse of thromboprophylaxis in patients hospitalized in medical wards. More efforts are urgently needed to develop new or endorse existing explicit, evidence-based criteria and guidelines for thromboprophylaxis in this population of patients.
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Affiliation(s)
- P Chopard
- Faculty of Medicine, University Hospitals, Geneva, Switzerland.
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Stinnett JM, Pendleton R, Skordos L, Wheeler M, Rodgers GM. Venous thromboembolism prophylaxis in medically ill patients and the development of strategies to improve prophylaxis rates. Am J Hematol 2005; 78:167-72. [PMID: 15726600 DOI: 10.1002/ajh.20281] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Venous thromboembolism (VTE) is common but often unrecognized in medically ill patients. Over the past 5 years, three large-scale placebo-controlled trials enrolling a total of 5500 medically ill patients have highlighted the risk of VTE in this group. These trials have helped to define a specific at-risk patient profile, including those admitted to the hospital with severe congestive heart failure, respiratory illness, acute infection, and inflammatory bowel disease. We performed a retrospective review of patients admitted to the medical service at our tertiary care center to define how common the at-risk medical patient is and to evaluate and improve prophylaxis rates in this patient group. The study was conducted in two phases. Based on admission characteristics, patients were stratified into high-risk or low-risk groups for the development of VTE. During the pre-intervention phase, 75% of patients admitted to the medical service were characterized as increased risk for VTE, yet only 43% of these high-risk patients received prophylaxis of any sort. After interventions designed to increase awareness of VTE, we conducted a second review period. In this post-intervention phase, where 79% of patients were at risk for VTE, prophylaxis rates improved to 72%. Based on these results, we conclude that the majority of patients admitted to the medical service at our tertiary care center constitute a high-risk population that warrants consideration for VTE prophylaxis. Implementation of strategies to improve prophylaxis rates, including educational sessions and risk stratification guidelines, can be successful and improve identification and prophylaxis of this population.
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Abstract
Autopsies and clinical studies have shown that venous thromboembolism (VTE) is a common cause of morbidity and mortality in medical patients. Prophylaxis of VTE has been less extensively studied in medical patients than in surgical patients, and the results of recent practice audits indicate that the use of thromboprophylaxis is uncommon in medical patients. In the past few years, 3 large randomized clinical trials have demonstrated the efficacy and safety of prophylaxis of VTE in the medical setting. The prophylaxis in MEDical patients with ENOXaparin (MEDENOX), Prospective Evaluation of Dalteparin Efficacy for PREVENTion of VTE in Immobilized Patients Trial (PREVENT), and ARixta for ThromboEmbolism Prevention in a Medical Indications Study (ARTEMIS) studies have compared the low-molecular-weight heparins enoxaparin and dalteparin, and the specific factor Xa inhibitor fondaparinux, respectively, with placebo in acutely ill medical patients hospitalized with heart failure, respiratory failure, infectious disease, or inflammatory disease. All studies showed both a statistically significant reduction in the rate of venous thromboembolic events (as assessed by venography or compression ultrasonography) and a rate of major bleeding events that were comparable to placebo. The results of these studies support the evidence-based recommendations for systematic use of thromboprophylaxis in this setting.
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Affiliation(s)
- Walter Ageno
- Department of Clinical Medicine, Ospedale di Circolo University of Insubria Varese, Italy.
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Abstract
Venous thromboembolism (VTE), a prevalent, costly medical condition, is one of the most common causes of death in the United States. Although risk factors for VTE are well known, thromboembolic events cannot be predicted because patients are asymptomatic and screening methods have limitations. Anticoagulant therapy (eg, low-molecular-weight heparin, unfractionated heparin, selective factor Xa inhibitors) has proved effective for preventing thromboembolism, including deep vein thrombosis and pulmonary embolism. While quality care for VTE entails prophylaxis for all relevant patients, many high-risk patients are undertreated or treated incorrectly. Both primary and secondary prevention of VTE remain inadequate for several reasons, including lack of awareness of the American College of Chest Physicians guidelines, of the seriousness of VTE, of the benefits of prophylaxis, and of the relatively low risk of bleeding complications. To provide appropriate treatment, physicians must assess the numbers and types of risk factors for each patient, the underlying illness or surgical procedure, and the benefits and risks of possible therapies. The problem of VTE will grow as the US population ages, as surgery is performed on increasingly sick patients, and as the length of hospital stays continues to decrease.
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Affiliation(s)
- Geno J Merli
- Division of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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