Thromboprophylaxis rates in US medical centers: success or failure?

Venous thromboembolism risk assessment scale for prediction of venous thromboembolism in inpatients with cancer: A meta-analysis

AIMS

This meta-analysis was conducted to evaluate the validity of the Caprini venous thromboembolism (VTE) risk assessment scale in predicting the risk of VTE in inpatients with cancer.

METHODS

Studies relating to the Caprini VTE risk assessment scale were systematically retrieved from the MEDLINE, EMBASE, Web of Science, Cochrane Library, BIOSIS Previews, EBSCOhost, and China National Knowledge Infrastructure (CNKI) databases up to May 1, 2022. Two reviewers independently conducted data extraction and quality evaluation. MetaDisc 1.4 and Stata 15.0 software were used for data analysis.

RESULTS

We included 10 studies with 23,644 subjects in our analyses. The results showed that the pooled sensitivity (SEN) and specificity (SPE) were 0.59 (95 % CI: 0.55 to 0.63) and 0.57 (95 % CI:0.57 to 0.58), respectively; the pooled diagnostic odds ratio (DOR) was 6.05 (95 % CI: 2.70 to 13.58); and the area under the curve (AUC) of the summary receiver operating characteristic (SROC) curve was 0.76. Subgroup analysis was performed according to ethnicity (Chinese or non-Chinese), study design (prospective/retrospective), Caprini RAM version (2005/2009), and cut-off (≤7 or > 7).

CONCLUSION

The Caprini VTE risk assessment scale has a moderate ability to predict VTE in surgical inpatients with cancer, as well as in Western populations; Caprini 2009 has a stronger predictive ability than 2005, and its predictive power is better if the cut-off value is >7. Future studies in clinical practice and specific specialties are needed to explore the optimal cut-off value of different cancers. This will improve our accuracy in understanding the risk of VTE in inpatients and help promote timely and targeted prevention. In turn, this will reduce the incidence of VTE and improve the quality of life of inpatients with cancer.

Association Between Venous Thromboembolism Prophylaxis and the Incidence of Thromboembolism Following Orthopedic Procedures: A Cross-Sectional Study

INTRODUCTION

Venous thromboembolism (VTE) is a significant concern following orthopedic procedures, necessitating effective prophylactic measures. The rates of VTE prophylaxis, however, vary widely between institutions and nations, falling between 13% and 70% on average. In the absence of adequate thromboprophylaxis, pulmonary embolism, which accounts for 5% to 10% of mortality in hospitalized patients, is one of the leading causes of death. This study investigates the relationship between VTE prophylaxis and thromboembolism incidence, considering patient characteristics, risk assessment completion, anticoagulant prescription, and weight-bearing status.

OBJECTIVES

To evaluate the knowledge gap by examining the relationship between VTE prevention and the prevalence of thromboembolism also to examine the anticoagulant prescription trends for patients being discharged from orthopedic operations and to investigate the connection between post-procedure weight-bearing status and the development of VTE problems.

METHODOLOGY

A retrospective, cross-sectional design was employed, analyzing 200 orthopedic procedure patients from January to June of 2023 performed at Rehman Medical Institute. After getting ethical approval from the institutional ethical approval board, data were collected on the basis of variables encompassing patient attributes, surgery details, VTE risk factors, prophylaxis type, and VTE complications. Data was entered and analyzed via IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States), and the data were run through various tests including descriptive statistics, cross-tabulations, and chi-square. Results were then presented in the form of a table.

RESULTS

Among 200 individuals 24 individuals experienced VTE, while 176 did not. Significant gender-based VTE differences were observed (p = 0.01). Hypertension (HTN) showed a significant association (p = 0.04) with VTE. Major surgeries were correlated with higher VTE incidence (p = 0.03). Pharmacological prophylaxis reduced the occurrence of VTE (p = 0.01). Early mobilization and Ted stockings were correlated with lower VTE incidence (p = 0.04, p = 0.12).

CONCLUSION

This study reveals gender-specific VTE differences, emphasizes the role of HTN, surgical nature, and prophylaxis in VTE incidence, and supports tailored prophylactic strategies. Our findings align with previous research and emphasize the significance of tailored prophylaxis strategies. By examining multiple factors, including gender, co-morbidities, surgical characteristics, and prophylactic methods, our study contributes to the evidence base that supports clinical decision-making and enhances patient safety in orthopedic surgery.

Prediction of in-hospital bleeding in acutely ill medical patients: External validation of the IMPROVE bleeding risk score

INTRODUCTION

Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data.

METHODS

We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC).

RESULTS

Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB.

CONCLUSION

The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted.

Characterizing geographic variation in postoperative venous thromboembolism

OBJECTIVE

Venous thromboembolism (VTE) after major surgery remains an important contributor to morbidity and mortality. Despite significant quality improvement efforts in prevention and prophylaxis strategies, the degree of hospital and regional variation in the United States remains unknown.

METHODS

Medicare beneficiaries undergoing 13 different major surgeries at U.S. hospitals between 2016 and 2018 were included in this retrospective cohort study. We calculated the rates of 90-day VTE. We adjusted for a variety of patient and hospital covariates and used a multilevel logistic regression model to calculate the rates of VTE and coefficients of variation across hospitals and hospital referral regions (HRRs).

RESULTS

A total of 4,115,837 patients from 4116 hospitals were included, of whom 116,450 (2.8%) experienced VTE within 90 days. The 90-day VTE rates varied substantially by procedure, from 2.5% for abdominal aortic aneurysm repair to 8.4% for pancreatectomy. Across the hospitals, there was a 6.6-fold variation in index hospitalization VTE and a 5.3-fold variation in the rate of postdischarge VTE. Across the HRRs, there was a 2.6-fold variation in 90-day VTE, with a 12.1-fold variation in the coefficient of variation. A subset of HRRs was identified with both higher VTE rates and higher variance across hospitals.

CONCLUSIONS

Substantial variation exists in the rate of postoperative VTE across U.S. hospitals. Characterizing HRRs with high overall rates of VTE and those with significant variation across the hospitals will allow for targeted quality improvement efforts.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Education and clinical pharmacist-led management strategies for the risk and prophylaxis of venous thromboembolism in general surgery

BACKGROUND

Despite the risks of venous thromboembolism (VTE) in surgical patients are well defined, primary thromboprophylaxis (TP) can be neglected. The aim of this study was to evaluate the risk of VTE and appropriateness of TP and to assess the effects of education and clinical pharmacy (CP) services.

METHODS

This study was conducted in a total of 3 periods (n = 800): pre-education (n = 340), post-education (n = 269) and CP intervention period (n = 191) and the risk of VTE and the appropriateness of TP were evaluated. At the end of pre-education period, patients were re-evaluated after education was given about the guidelines on TP and an educative poster was posted in the services (post-education period). During the CP intervention period, the CP made recommendations in terms of optimal TP use to the physicians in charge.

RESULTS

While there was no significant difference in the optimal TP rate administered to the patients before and after education (138/340, 40.6% vs. 122/269, 45.4%; p = 0.238); this rate was increased to 113/191 (59.2%) in the CP intervention period (p = 0.004). High-risk patients who received one type of TP constituted the majority of patients who did not receive optimal TP. While the ratio of high-risk patients undergoing a single type of TP in the pre- and post-education periods (104/340, 30.6% vs. 83/269, 30.9%), was similar (p = 0.819); with the CP interventions, this rate was reduced to 35/191 (18.3%) (p = 0.001).

CONCLUSION

Even though education has positive influence on surgeons, the implementation of CP practices is more effective especially in terms of maintaining optimal TP.

Doctors Identify Hemorrhage Better during Chart Review when Assisted by Artificial Intelligence

OBJECTIVES

This study evaluated if medical doctors could identify more hemorrhage events during chart review in a clinical setting when assisted by an artificial intelligence (AI) model and medical doctors' perception of using the AI model.

METHODS

To develop the AI model, sentences from 900 electronic health records were labeled as positive or negative for hemorrhage and categorized into one of 12 anatomical locations. The AI model was evaluated on a test cohort consisting of 566 admissions. Using eye-tracking technology, we investigated medical doctors' reading workflow during manual chart review. Moreover, we performed a clinical use study where medical doctors read two admissions with and without AI assistance to evaluate performance when using and perception of using the AI model.

RESULTS

The AI model had a sensitivity of 93.7% and a specificity of 98.1% on the test cohort. In the use studies, we found that medical doctors missed more than 33% of relevant sentences when doing chart review without AI assistance. Hemorrhage events described in paragraphs were more often overlooked compared with bullet-pointed hemorrhage mentions. With AI-assisted chart review, medical doctors identified 48 and 49 percentage points more hemorrhage events than without assistance in two admissions, and they were generally positive toward using the AI model as a supporting tool.

CONCLUSION

Medical doctors identified more hemorrhage events with AI-assisted chart review and they were generally positive toward using the AI model.

Risk and factors associated with venous thromboembolism following abdominal transplantation

Background

Venous thromboembolism (VTE) remains under-studied among patients undergoing kidney, liver and pancreas (abdominal) transplantation. We characterized the risk and predictors of VTE using a nationally-representative cohort.

Methods

The 2014-2019 Nationwide Readmissions Database was queried to identify all adults undergoing abdominal transplantation. Patients who developed pulmonary embolism or deep venous thrombosis were considered the VTE cohort (others: nonVTE). Multivariable models were developed to identify factors linked with VTE and assess the independent associations between VTE and key outcomes.

Results

Of ~141,977 transplant recipients, 1.9 % (2722) developed VTE. The VTE cohort was similarly female (39.2 vs 38.0, p = 0.51), but more often demonstrated a higher Elixhauser comorbidity index (4.19 ± 1.40 vs 3.93 ± 1.39, p < 0.001).After adjustment, congestive heart failure (AOR 1.54, 95%CI 1.25-1.91), cardiac arrhythmias (AOR 1.54, 95%CI 1.34-1.78), peripheral vascular disease (AOR 1.29, 95%CI 1.02-1.63), coagulopathies (AOR 1.63, 95%CI 1.38-1.92), previous history of VTE (AOR 1.14, 95%CI 1.06-1.22), and heparin-induced thrombocytopenia (AOR 2.61, 95%CI 2.07-3.28) were associated with VTE. The development of VTE was linked with significantly greater in-hospital mortality (AOR 4.56, 95%CI 2.07-10.10), as well as infectious (AOR 2.59, 95%CI 1.55-4.21), cardiac (AOR 2.59, 95%CI 1.39-4.82), and respiratory (AOR 1.78, 95%CI 1.21-2.63) complications. VTE was further associated with increased length of stay (+8.18 days, 95%CI +1.32-15.41), expenditures (+$42,000, 95%CI $24,800-59,210), and odds of VTE upon readmission (AOR 4.51, 95%CI 1.32-15.41).

Conclusions

VTE after abdominal transplantation is linked with significantly greater in-hospital mortality, complications, resource utilization, and risk of VTE at readmission. Novel risk assessments and prophylaxis protocols are needed to reduce VTE incidence and sequelae.

Secondary prevention of venous thromboembolism: Predictors and outcomes of guideline adherence in a long-term prospective cohort study

Background

Prevention of recurrent venous thromboembolism (VTE) is considered a main goal of VTE management. However, the extent to which physicians adhere to the recommendations from evidence-based guidelines is unknown.

Aim

From a large, prospective clinical cohort, we aimed to (1) quantify the adherence of treatment recommendations to evidence-based guidelines and establish its predictors, and (2) estimate its impact on clinical outcomes and costs in patients with VTE.

Methods

We included 6'243 consecutive patients with VTE treated at the university outpatient unit. Detailed clinical characteristics and treatment recommendations were recorded. Adherence of treatment recommendations to evidence-based guidelines at risk assessment was assessed in terms of duration of anticoagulant treatment. Data on death were obtained from the Swiss Central Compensation Office. Health care claims data recorded between 2014 and 2019 were retrieved from Helsana, one of the largest Swiss health insurance companies.

Results

The adherence to evidence-based guidelines was 36.1%. Among patients with non-adherence, overtreatment was present in 70.1%. Significant patient-related predictors of guideline adherence were (a) age above 50 years, (b) male sex, (c) pulmonary embolism, (d) unprovoked VTE, (e) multiple VTE, (f) laboratory tests not ordered, and (g) various cardiovascular comorbidities. Non-adherence was not significantly associated with mortality, hospitalization, admission to nursing home, and costs.

Conclusions

The adherence to evidence-based guidelines was low, and several unrelated predictors appeared. Although these results need to be confirmed in other settings, they highlight the need for implementation of evidence-based guidelines in clinical practice.

Incidence of thromboembolism and thromboprophylaxis in medical patients admitted to specialized hospital in Ethiopia using Padua prediction score

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.

Quality gap in venous thromboembolism prophylaxis practices in inpatients: Assessment of prophylaxis practices in a University Hospital

BACKGROUND

Venous thromboembolism (VTE) is a prevalent complication of inpatient care, causing high burden of morbidity and mortality. Prophylaxis reduces the events; thus, these practices are promoted. We aimed to assess the VTE prophylaxis practices in the general internal medicine wards of a tertiary-care university hospital and utilize these data to propose quality improvement projects.

OBJECTIVE

Assess the pharmacological venous thromboembolism prophylaxis utilization by using the Padua Prediction Score and demonstrate the main determinants of inappropriate prophylaxis use.

METHODS

Electronic medical records were used to collect data cross-sectionally from 1 January 2019 to 30 June 2019. Padua Prediction Score was used to assess the appropriateness of VTE prophylaxis. Underlying health conditions, hospitalization causes, anti-platelets and use of glucocorticoids were also assessed as confounding factors.

RESULTS

A total of 295 patients were included. Higher proportion of patients who received VTE prophylaxis were obese and had higher rates of diabetes and coronary artery disease. Prophylaxis was more commonly utilized among patients who were elderly, obese, having an acute infection and/or rheumatologic disorder and prolonged bed rest (P ≤ 0.001, P = 0.01, P = 0.22 and P ≤ 0.001, respectively). Thirty-five patients (11.8%) received VTE prophylaxis, despite 89 patients (30.2%) were high-risk patients. In the high-risk group (n = 89), 27 patients (30.3%) received appropriate pharmacological prophylaxis, while 8 patients (3.9%) received VTE prophylaxis in the low-risk group (total n = 206). A considerable percentage of the high-risk population (69.6%) did not receive VTE prophylaxis.

DISCUSSION

Underuse constitutes a major challenge in our hospital but differing from other institutions, overuse is not a significant issue. Further studies are needed whether VTE prophylaxis improvement implementations uniformly increase appropriate VTE use.

Clinical practice guidelines for the treatment and prevention of cancer-associated thrombosis

The risk of venous thromboembolism (VTE) is increased in patients with cancer and is greatest in those with cancers of the pancreas, stomach, brain, lung and ovary, late stage disease and in those undergoing treatment including chemotherapy, hormonal therapy, or surgery. VTE in patients with cancer is associated with a variety of adverse consequences including an increased risk of VTE recurrence, major bleeding, and early mortality. A VTE risk score for ambulatory patients receiving cancer chemotherapy has been extensively validated and has been used to select high risk patients for thromboprophylaxis trials. Several randomized controlled trials (RCTs) and meta-analyses of these trials have confirmed that LMWHs can significantly reduce the risk of VTE in patients with cancer. While the direct oral anticoagulants (DOACs) have been approved for the general population, previous guideline panels discouraged their use due to a lack of cancer-specific data. Recently RCTs for the treatment of established VTE in patients with cancer have demonstrated that the risk of recurrent VTE is lower while the risk of bleeding greater with DOACs compared to LMWH. Two thromboprophylaxis trials comparing low dose DOACs to placebo in high risk patients receiving cancer therapy have recently reported similar rates of VTE occurrence at 6 months in the control arms. A meta-analysis of the pooled results from these trials in higher risk ambulatory patients receiving cancer therapy confirmed a significant reduction in overall VTE incidence as well as pre-planned secondary outcomes on treatment. Several clinical practice guidelines addressing VTE in patients with malignant disease have been updated including those from the American Society of Clinical Oncology (ASCO). The addition of DOACs as an option for the management of VTE in patients with cancer is the latest major change to previous guidelines issued by these organizations. The updated recommendations from these guidelines are summarized in this review.

Heparins have adequate ex vivo anticoagulant effects in hospitalized patients with cirrhosis

BACKGROUND

Patients with cirrhosis are at risk of venous thromboembolism (VTE), but strategies for thromboprophylaxis have not been defined. Previous in vitro studies suggest an altered anticoagulant effect of heparins in patients with cirrhosis.

OBJECTIVES

To assess the anticoagulant effects of prophylactic low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) doses in patients with cirrhosis in a real-life clinical setting.

METHODS

We studied patients with cirrhosis (n = 16) and acute-on-chronic liver failure (ACLF) (n = 14), and compared these with patients without underlying liver disease admitted to non-liver general medical wards (n = 18) and non-liver intensive care units (n = 14), respectively. Blood samples were taken before and 4 h after administration of the first dose of LMWH or UFH. We assessed hemostatic status using thrombin generation assays, thrombin-antithrombin complexes (TAT), and conventional coagulation assays, and included healthy controls (n = 20) to establish reference values. Anti-Xa activity was determined to estimate peak heparin levels.

RESULTS

Baseline thrombin generation was similar among all cohorts and healthy controls despite alterations in conventional coagulation assays. On heparin, both absolute and proportional changes of thrombin generation were comparable between all four cohorts (-62% to -85%). TAT levels decreased in all cohorts apart from the ACLF cohort, but did not correlate with the proportional change in thrombin generation. Anti-Xa activity correlated with the proportional change in thrombin generation in patients receiving LMWH, but not in patients receiving UFH.

CONCLUSIONS

These data suggest that current prophylactic heparin doses have comparable anticoagulant effects in patients with cirrhosis compared with patients without underlying liver disease.

Deep learning detects and visualizes bleeding events in electronic health records

BACKGROUND

Bleeding is associated with a significantly increased morbidity and mortality. Bleeding events are often described in the unstructured text of electronic health records, which makes them difficult to identify by manual inspection.

OBJECTIVES

To develop a deep learning model that detects and visualizes bleeding events in electronic health records.

PATIENTS/METHODS

Three hundred electronic health records with International Classification of Diseases, Tenth Revision diagnosis codes for bleeding or leukemia were extracted. Each sentence in the electronic health record was annotated as positive or negative for bleeding. The annotated sentences were used to develop a deep learning model that detects bleeding at sentence and note level.

RESULTS

On a balanced test set of 1178   sentences, the best-performing deep learning model achieved a sensitivity of 0.90, specificity of 0.90, and negative predictive value of 0.90. On a test set consisting of 700 notes, of which 49 were positive for bleeding, the model achieved a note-level sensitivity of 1.00, specificity of 0.52, and negative predictive value of 1.00. By using a sentence-level model on a note level, the model can explain its predictions by visualizing the exact sentence in a note that contains information regarding bleeding. Moreover, we found that the model performed consistently well across different types of bleedings.

CONCLUSIONS

A deep learning model can be used to detect and visualize bleeding events in the free text of electronic health records. The deep learning model can thus facilitate systematic assessment of bleeding risk, and thereby optimize patient care and safety.

Safety and effectiveness of thromboprophylaxis use in hospitalized elderly medical patients at a Saudi tertiary care center

Introduction

Appropriate prescribing of thromboprophylaxis according to guidelines' recommendations can heighten over- or underutilization risk. The study intended to evaluate the safety and effectiveness of appropriate/inappropriate thromboprophylaxis use among hospitalized elderly medical patients.

Methods

A retrospective observational cohort study was conducted, including patients who were ≥60 years old, hospitalized for an acute medical illness that required hospitalization in a medical ward for >48 h, and received thromboprophylaxis. Against the American College of Chest Physicians guidelines, the thromboprophylaxis use appropriateness was assessed.

Results

A total of 370 patients met the inclusion criteria, in 71.9% of whom thromboprophylaxis use was appropriate. The mean age of the included patients was 75 years (±9.1), and 72.4% of them were at high risk of venous thromboembolism (VTE), and almost all these patients received appropriate thromboprophylaxis. The occurrence of bleeding was significantly higher in the appropriate use group during hospitalization than the inappropriate use group (11.7% vs. 2.9%, p = 0.009); the majority of these bleeding events were classified as major. There were no differences in VTE events during hospitalization or 90 days all-cause mortality between the two groups.

Conclusion

The study demonstrates high prescribers' compliance with recommendations in high-risk patients. In patients at low risk for VTE, the overutilization of thromboprophylaxis did not increase their bleeding risk. This study suggests that the benefits of thromboprophylaxis in elderly patients, regardless of their VTE risk, may outweigh the risk of bleeding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Thromboembolism prophylaxis in orthopaedics: an update

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.

Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.

VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery.

Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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

Evaluation of Appropriate Venous Thromboembolism Prophylaxis in Patients With Orthopaedic Trauma With Symptom-Driven Vascular and Radiographic Studies

OBJECTIVE

To evaluate venous thromboembolism (VTE) prophylaxis adherence and effectiveness in orthopaedic trauma patients who had vascular or radiographic studies showing deep vein thromboses or pulmonary emboli.

DESIGN

Retrospective review.

SETTING

A level I trauma center that independently services a 5-state region.

PATIENTS

Four hundred seventy-six patients with orthopaedic trauma who underwent operative treatments for orthopaedic injuries and had symptom-driven diagnostic VTE studies.

INTERVENTION

The medical records of patients treated surgically between July 2010 and March 2013 were interrogated using a technical tool that electronically captures thrombotic event data from vascular and radiologic imaging studies by natural language processing.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated for hospital guideline-directed VTE prophylaxis adherence with mechanical or chemical prophylaxis. Patient demographics, associated injuries, mechanism of injury, and symptoms that led to imaging for a VTE were also assessed.

RESULTS

Of the 476 orthopaedic patients who met inclusion criteria, 100 (mean age 52.3 median 52, SD 18.3, 70% men) had positive VTE studies. Three hundred seventy-six (age 47.3, SD 17.3, 69% men) had negative VTE studies. Of the 100 patients with VTE, 63 deep vein thromboses, and 49 pulmonary emboli were found. Eight-five percent of all patients met hospital guideline-VTE prophylaxis standards.

CONCLUSION

The study population had better than previously reported VTE prophylaxis adherence, however, patients still developed VTEs.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Disease burden and unmet needs for prevention of venous thromboembolism in medically ill patients in Europe show underutilisation of preventive therapies

It was the aim of this review to assess the incidence of venous thromboembolism (VTE) and current practice patterns for VTE prophylaxis among medical patients with acute illness in Europe. A literature search was conducted on the epidemiology and prophylaxis practices of VTE prevention among adult patients treated in-hospital for major medical conditions. A total of 21 studies with European information published between 1999 and April 2010 were retrieved. Among patients hospitalised for an acute medical illness, the incidence of VTE varied between 3.65% (symptomatic only over 10.9 days) and 14.9% (asymptomatic and symptomatic over 14 days). While clinical guidelines recommend pharmacologic VTE prophylaxis for patients admitted to hospital with an acute medical illness who are bedridden, clear identification of specific risk groups who would benefit from VTE prophylaxis is lacking. In the majority of studies retrieved, prophylaxis was under-used among medical inpatients; 21% to 62% of all patients admitted to the hospital for acute medical illnesses did not receive VTE prophylaxis. Furthermore, among patients who did receive prophylaxis, a considerable proportion received medication that was not in accord with guidelines due to short duration, suboptimal dose, or inappropriate type of prophylaxis. In most cases, the duration of VTE prophylaxis did not exceed hospital stay, the mean duration of which varied between 5 and 11 days. In conclusion, despite demonstrated efficacy and established guidelines supporting VTE prophylaxis, utilisation rates and treatment duration remain suboptimal, leaving medical patients at continued risk for VTE. Improved guideline adherence and effective care delivery among the medically ill are stressed.

Venous thromboembolism in patients with symptomatic atherosclerosis

Patients with atherosclerosis have an increased risk of venous thromboembolism (VTE). We studied patients in the population-based Worcester VTE Study of 1,822 consecutive patients with validated VTE to compare clinical characteristics, prophylaxis, treatment, and outcomes of VTE in patients with and without symptomatic atherosclerotic cardiovascular disease, defined as history of ischaemic heart disease, history of positive cardiac catheterisation, percutaneous coronary intervention, or coronary artery bypass graft surgery, or history of peripheral artery disease. Of the 1,818 patients with VTE, 473 (26%) had a history of symptomatic atherosclerosis. Patients with atherosclerosis were significantly older (mean age 71.9 years vs. 61.6 years) and were more likely to have immobility (57.2% vs. 46.7%), prior heart failure (36.9% vs. 10.7%), chronic lung disease (26.4% vs. 15.5%), cerebrovascular disease (18.1% vs. 9.8%), and chronic kidney disease (4.9% vs. 1.9%) (all p<0.001) compared with non-atherosclerosis patients. Thromboprophylaxis was omitted in more than one-third of atherosclerosis patients who had been hospitalised for non-VTE-related illness or had undergone major surgery within the three months prior to VTE. Patients with atherosclerosis were significantly more likely to suffer in-hospital major bleeding (7.6% vs. 3.8%, p=0.0008). In conclusion, patients with atherosclerosis and VTE are more likely to suffer a complicated hospital course. Despite a high frequency of comorbid conditions contributing to the risk of VTE, we observed a low rate of thromboprophylaxis in patients with symptomatic atherosclerosis.

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

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

Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery

BACKGROUND

Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States.

OBJECTIVE

To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis.

METHODS

Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering.

RESULTS

A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis.

CONCLUSION

Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7 years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.

Thromboprophylaxis Failure in the Adult Medical Inpatient

Venous thromboembolism (VTE), a leading cause of morbidity and mortality among hospitalized patients, is often due to prophylaxis failure rather than omission, but few studies have identified the risk factors for failure. Risk factors for thromboprophylaxis failure include personal or family history of VTE, use of vasopressors or inotropes, increased body mass index, cranial surgery, intensive care patient, leukocytosis, indwelling central venous catheter and admission from a long-term care facility. Identifying patients at risk for thromboprophylaxis failure should prompt close observation during hospitalization for signs of VTE, close observation after discharge and potentially more aggressive prophylaxis strategies, although no specific guidelines exist for medical patients at this time.

Cancer and Venous Thromboembolic Disease: A Review

Venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in cancer patients. Patients with cancer are six times more likely to develop VTE than their noncancer counterparts, and VTE is the second leading cause of death in cancer patients. Despite the publication of major consensus guidelines setting out recommendations for thromboprophylaxis in cancer patients, there remains a gulf between these guidelines and clinical practice. In general, thromboprophylaxis is recommended for most patients hospitalized with active cancer. Furthermore, outpatient thromboprophylaxis may be used in carefully selected high-risk ambulatory patients. Certain areas of controversy still remain. Although low-molecular-weight heparin has been shown to be superior to vitamin K antagonists in cancer patients, the role of direct oral anticoagulants is still uncertain. Moreover, recurrent thromboembolism, bleeding, and thrombocytopenia are frequently seen in cancer patients. Optimal anticoagulation in such instances presents a major challenge to clinicians. Modern computed tomography techniques have resulted in an increase in the detection of "incidental" VTE. Despite a growing body of evidence promulgating standard anticoagulant treatment in such cases, these cases present further challenges for members of the multidisciplinary team. The Oncologist 2017;22:199-207Implications for Practice: This article discusses venous thromboembolism (VTE) in patients with malignancy. Practical guidance is offered on how to prevent, diagnose, and treat VTE in cancer patients. The management of "challenging" cases of VTE is also discussed.

Prevalence and factors associated with the absence of pharmacologic venous thromboembolism prophylaxis: A cross-sectional study of Georgia intensive care units

PURPOSE

The need for venous thromboembolism prophylaxis is well accepted in the intensive care unit (ICU) and supported by a variety of guideline recommendations. Several studies have highlighted poor adherence to these recommendations, but it is unknown why this discrepancy exists. The aim of this study is assess the prevalence of pharmacoprophylaxis and characterize the practice of withholding prophylaxis.

MATERIALS AND METHODS

Multicenter, cross-sectional study conducted in adults admitted to a Georgia ICU at participating institutions on March 12, 2014. Data were collected on eligible patients regarding need for and omission of pharmacoprophylaxis.

RESULTS

Three hundred sixty-four patients across 9 institutions were included in the study. Patients had a mean age of 58 years and a median Sequential Organ Failure Assessment score of 5. Physical activity was completely bedridden or restricted in 87% of the cohort. Forty-five percent of patients were not receiving pharmacoprophylaxis. The most common reasons for withholding prophylaxis were receipt of mechanical prophylaxis, recent surgery or central nervous system bleed, and thrombocytopenia. Over 16% of the cohort was inappropriately not receiving thromboprophylaxis. Patients with an elevated international normalized ratio had lower odds of receiving prophylaxis (0.2).

CONCLUSIONS

Venous thromboembolism prophylaxis is commonly omitted in ICU patients, and reasons for omission vary. An elevated international normalized ratio is associated with withholding of pharmacologic prophylaxis.

Improving venous thromboembolism risk assessment compliance using the electronic tool in admitted medical patients

Sheikh Khalifa Medical City (SKMC) in Abu Dhabi is the main tertiary care referral hospital in the United Arab Emirates (UAE) with 560 bed capacity that is fully occupied most of the time. SKMC senior management has made a commitment to make quality and patient safety a top priority. Venous thromboembolism (VTE) risk assessment has been identified as a critical patient safety measure and key performance indicator. The electronic VTE risk assessment form a computerized decision support tool was introduced to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations. A multidisciplinary task force team was formed and led this quality improvement project. The purpose of this publication is to indicate the quality improvement interventions implemented to enhance compliance with VTE risk assessment and the outcomes of those interventions. We chose to conduct the pilot study in General Medicine as it is the busiest department in the hospital. The study period was from April 2014 till August 2015.The lessons learned were disseminated throughout the hospital. Our aim was to improve VTE risk assessment compliance by using the electronic form in order to ensure patient safety and reduce preventable harm. VTE risk assessment compliance improved in general medicine from 4% to 98%, and overall SKMC compliance from 21% to above 90%.

A common data model to assess cardiovascular hospitalization and mortality in atrial fibrillation patients using administrative claims and medical records

Purpose

Atrial fibrillation/flutter (AF) is frequently associated with cardiovascular comorbidities. Observational health care databases are commonly used for research purposes in studies of quality of care, health economics, outcomes research, drug safety, and epidemiology. This retrospective cohort study applied a common data model to administrative claims data (Truven Health Analytics MarketScan^® claims databases [MS-Claims]) and electronic medical records data (Geisinger Health System’s MedMining electronic medical record database [MG-EMR]) to examine the risk of cardiovascular hospitalization and all-cause mortality in relation to clinical risk factors in recent-onset AF and to assess the consistency of analyses for each data source.

Methods

Cohorts of patients with newly diagnosed AF (n=105,262 [MS-Claims] and n=3,919 [MG-EMR]) and demographically similar patients without AF (n=105,262 [MS-Claims] and n=3,872 [MG-EMR]) were followed from the qualifying AF diagnosis until cardiovascular hospitalization, death, database disenrollment, or study completion. A common data model standardized the data in structure, format, content, and nomenclature to allow for systematic assessment and comparison of outcomes from two disparate data sets.

Results

In both databases, AF patients had greater overall baseline comorbidity and higher incidence rates of cardiovascular hospitalization (threefold higher) and all-cause mortality (46% higher) than non-AF patients. For AF patients, incidence rates of cardiovascular hospitalization and all-cause mortality were increased by the concomitant presence of coronary disease, chronic obstructive pulmonary disease, and stroke at baseline. Overall, the pattern of cardiovascular hospitalization in the MS-Claims database was similar to that in the MG-EMR database. Compared with the MS-Claims database, the use of cardiovascular medications and the capture of certain comorbidities among AF patients appeared to be higher in the MG-EMR data set.

Conclusion

Similar standardized analyses across EMR and Claims databases were consistent in the association of AF with acute morbidity and an increased risk of all-cause mortality. Areas of inconsistency were due to differences in underlying population demographics and cardiovascular risks and completeness of certain data fields.

Impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the emergency department

AIMS

The aim of the study was to evaluate the impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the Emergency Department (ED) by assessing prescribing appropriateness at admission.

METHODS

A cross-sectional, observational, descriptive study was designed and included all adult medical patients admitted from an ED between 20 November 2012 and 26 November 2012 at a large tertiary hospital. Patients to whom anticoagulants were prescribed for therapeutic purposes, patients admitted to Intensive Care Unit or maternity wards were excluded. Prescribing appropriateness was assessed using the Padua Prediction Score (ACCP 2012 guideline) for thromboembolic risk assessment and the NICE model to determine risk of bleeding. The primary end-point was the adequacy of thromboprophylaxis prescribed at the ED according to the ACCP 2012 guideline.

RESULTS

A total of 393 patients were examined and 207 patients were included in the study (53.1% were male) with a median age of 75.3 years. The most common diagnosis at admission was related to a respiratory disease (41.1%). In 34.8% of the patients (72 patients), the recommendation of prophylaxis according to ACCP 2012 guideline did not match with the prophylaxis prescribed at admission. Reasons for non-concordance were undertreatment (14.5%) and overtreatment (20.3%).

CONCLUSIONS

The adequacy of thromboprophylaxis in high risk patients for VTE has improved compared with the ENDORSE study. However, the percentage of patients with discordant prescriptions remains high. Despite the existence of treatment omissions, this percentage has been overcome by patients overtreated.

Cancer and venous thromboembolic disease: from molecular mechanisms to clinical management

Venous thromboembolism (vte) represents a major challenge in the management of patients with cancer. The malignant phenotype is associated with derangements in the coagulation cascade that can manifest as thrombosis, hemorrhage, or disseminated intravascular coagulation. The risk of vte is increased by a factor of approximately 6 in patients with cancer compared with non-cancer patients, and cancer patients account for approximately 20% of all newly diagnosed cases of vte. Postmortem studies have demonstrated rates of vte in patients with cancer to be as high as 50%. Despite that prevalence, vte prophylaxis is underused in hospitalized patients with cancer. Studies have demonstrated that hospitalized patients with cancer are less likely than their non-cancer counterparts to receive vte prophylaxis. Consensus guidelines address the aforementioned issues and emerging concepts in the area, including the use of risk-assessment models, biomarkers to identify patients at highest risk of vte, and use of anticoagulants as anticancer therapy. Despite those guidelines, a gulf exists between current recommendations and clinical practice; greater efforts are thus required to ensure effective implementation of strategies to reduce the incidence of vte in patients with cancer.

Pattern of frequent but nontargeted pharmacologic thromboprophylaxis for hospitalized patients with cancer at academic medical centers: a prospective, cross-sectional, multicenter study

PURPOSE

Hospitalized patients with cancer are considered to be at high risk for venous thromboembolism (VTE). Despite strong recommendations in numerous clinical practice guidelines, retrospective studies have shown that pharmacologic thromboprophylaxis is underutilized in hospitalized patients with cancer.

PATIENTS AND METHODS

We conducted a prospective, cross-sectional study of hospitalized patients with cancer at five academic hospitals to determine prescription rates of thromboprophylaxis and factors influencing its use during hospitalization.

RESULTS

A total of 775 patients with cancer were enrolled across five academic medical centers. Two hundred forty-seven patients (31.9%) had relative contraindications to pharmacologic prophylaxis. Accounting for contraindications to anticoagulation, the overall rate of pharmacologic thromboprophylaxis was 74.2% (95% CI, 70.4% to 78.0%; 392 of 528 patients). Among the patients with cancer without contraindications for anticoagulation, individuals hospitalized with nonhematologic malignancies were significantly more likely to receive pharmacologic thromboprophylaxis than those with hematologic malignancies (odds ratio [OR], 2.34; 95% CI, 1.43 to 3.82; P=.007). Patients with cancer admitted for cancer therapy were significantly less likely to receive pharmacologic thromboprophylaxis than those admitted for other reasons (OR, 0.37; 95% CI, 0.22 to 0.61; P<.001). Sixty-three percent of patients with cancer classified as low risk, as determined by the Padua Scoring System, received anticoagulant thromboprophylaxis. Among the 136 patients who did not receive anticoagulation, 58.8% were considered to be high risk by the Padua Scoring System.

CONCLUSION

We conclude that pharmacologic thromboprophylaxis is frequently administered to hospitalized patients with cancer but that nearly one third of patients are considered to have relative contraindications for prophylactic anticoagulation. Pharmacologic thromboprophylaxis in hospitalized patients with cancer is commonly prescribed without regard to the presence or absence of concomitant risk factors for VTE.

Conventional and new oral anticoagulants in the treatment of chest disease and its complications

Oral anticoagulants block the coagulation cascade either by an indirect mechanism (e.g., vitamin K antagonists) or by a direct one (e.g., the novel oral anticoagulants). Vitamin K antagonists are widely used as treatment of venous thromboembolism and for stroke prevention in patients with atrial fibrillation. Although low molecular weight heparin remains the first line in venous thromboembolism prophylaxis, more recently the novel oral anticoagulants such as dabigatran (initial dose of 110 mg within 1-4 h after surgery, followed by the full dose of 220 mg once daily), rivaroxaban (dose of 10 mg once daily, with the first dose administered 6-10 h after the surgery), and apixaban (dose of 2.5 mg twice daily, starting 12-24 h after surgery, but available only in Europe) are approved for prophylaxis in patients undergoing major orthopedic surgery. The period in which thromboembolic risk abates remains uncertain, and trials of extended therapy are still ongoing. After showing at least noninferiority to warfarin in RE-LY, ROCKET-AF, and ARISTOTLE trials, dabigatran (110 or 150 mg twice daily), rivaroxaban (20 or 15 mg once daily), and apixaban (5 mg twice daily), respectively, were approved also for stroke prevention in patients with atrial fibrillation. While awaiting long-term safety data, the choice among all these available therapies should be based on patient preferences, compliance, and ease of administration, as well as on local factors affecting cost-effectiveness.

Bleeding and venous thromboembolism arising in acutely ill hospitalized medical patients. Findings from the Spanish national discharge database

BACKGROUND

There is scarce evidence to identify which acutely ill medical patients might benefit from prophylaxis against venous thromboembolism (VTE).

METHODS

The Spanish National Discharge Database was used to identify predictors of bleeding and VTE during hospitalization for an acute medical illness.

RESULTS

Of 1,148,301 patients, 3.10% bled, 1.21% were diagnosed with VTE, and 8.64% died. The case-fatality rate was: 20.8% for bleeding and 19.7% for VTE. Eight clinical variables were independently associated with an increased risk for VTE and bleeding, one with a decreased risk for both events, 4 with an increased risk for VTE and a decreased risk for bleeding, 2 with an increased risk for bleeding but a decreased risk for VTE, and 1 with a decreased risk for bleeding. When all these variables were considered, we composed a risk scoring system, in which we assigned points to each variable according to the ratio between the odds ratio for bleeding and for VTE. Overall, 21% of patients scored less than 0 points and had a bleeding vs. VTE ratio of 1.19; 55% scored 0 to 1.0 points and had a ratio of 2.13; and 24% scored over 1.0 points and had a ratio of 6.10.

CONCLUSIONS

A risk score based on variables documented at admission can identify patients with different ratios (near 1.0; about 2.0; and >6.0) between the rate of bleeding and of VTE.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Are There Any Differences in the Clinical and Economic Outcomes Between US Cancer Patients Receiving Appropriate or Inappropriate Venous Thromboembolism Prophylaxis?

Prophylaxis is often underused and inappropriately prescribed. This study compares the efficacy and cost of appropriate and partial prophylaxis in cancer patients at risk for VTE.

Improving hospital venous thromboembolism prophylaxis with electronic decision support

BACKGROUND

Venous thromboembolism (VTE) disease prophylaxis rates among medical inpatients have been noted to be <50%.

OBJECTIVE

Our objective was to evaluate the effectiveness and safety of a computerized decision support application to improve VTE prophylaxis.

DESIGN

Observational cohort study.

SETTING

Academic medical center.

PATIENTS

Adult inpatients on hospital medicine and nonmedicine services.

INTERVENTION

A decision support application designed by a quality improvement team was implemented on medicine services in September 2009.

MEASUREMENTS

Effectiveness and safety parameters were compared on medicine services and nonmedicine (nonimplementation) services for 6-month periods before and after implementation. Effectiveness was evaluated by retrospective information system queries for rates of any VTE prophylaxis, pharmacologic VTE prophylaxis, and hospital-acquired VTE incidence. Safety was evaluated by queries for bleeding and thrombocytopenia rates.

RESULTS

Medicine service overall VTE prophylaxis increased from 61.9% to 82.1% (P < 0.001), and pharmacologic VTE prophylaxis increased from 59.0% to 74.5% (P < 0.001). Smaller but significant increases were observed on nonmedicine services. Hospital-acquired VTE incidence on medicine services decreased significantly from 0.65% to 0.42% (P = 0.008) and nonsignificantly on nonmedicine services. Bleeding rates increased from 2.9% to 4.0% (P < 0.001) on medicine services and from 7.7% to 8.6% (P = 0.043) on nonmedicine services, with nonsignificant changes in thrombocytopenia rates observed on both services.

CONCLUSIONS

An electronic decision support application on inpatient medicine services can significantly improve VTE prophylaxis and hospital-acquired VTE rates with a reasonable safety profile.