Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalized patients SWIss Venous ThromboEmbolism Registry (SWIVTER)

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.

Venous thromboembolism risk factors and usefulness of a risk scoring system in lower limb orthopedic surgery: A case-control study in Japan

We previously developed a computerized clinical decision support system based on national consensus guidelines and previous studies. This system was used to assess the risk of venous thromboembolism. In this study, we examined the risk factors for venous thromboembolism in patients who underwent lower limb orthopedic surgery using our risk scoring system, to investigate the association between the total risk score and the occurrence of venous thromboembolism.We retrospectively evaluated the records of 649 patients who underwent lower limb orthopedic surgery at a tertiary care center in Japan between January 2015 and August 2018. Venous thromboembolism was confirmed using ultrasonography or computed tomography angiography. The computerized clinical decision support system was used throughout the hospitalization period. Independent risk factors for postoperative venous thromboembolism were identified using logistic regression analysis.Age (≥68 years) was significantly associated with an increased risk of venous thromboembolism (adjusted odds ratio: 1.06, 95% confidence interval: 1.03-1.09; P < 0.001). Furthermore, the Cochran-Armitage trend test revealed a significant positive correlation between the total risk score and the occurrence of venous thromboembolism (P < 0.001).Our risk scoring system may be used preoperatively to determine the need for venous thromboembolism prophylaxis. This study suggests that age (≥68 years) may be a risk factor for venous thromboembolism after lower limb orthopedic surgery. Additional studies are needed to validate these results.

Analysis of Adherence to Thromboprophylaxis and Incidence of Venous Thromboembolism After Lower Limb Orthopaedic Surgery

Background

The economic burden caused by venous thromboembolism (VTE) to the National Health Service (NHS) is approximately £640 million. There is a significant national drive for VTE prophylaxis prescription given the high morbidity and mortality rates associated with VTE following lower limb orthopaedic surgery. The primary objective of this analysis was to examine the adherence to the updated VTE guidelines, NG89, by the National Institute for Health and Care Excellence (NICE) regarding prophylaxis for patients undergoing lower limb orthopaedic surgery, where the weight-bearing status will be reduced postoperatively, in an urban community hospital.

Methodology

We looked at 586 patients who underwent elective lower limb orthopaedic surgeries over a two year time period. We reviewed their VTE prophylaxis administration. Results were shared with the Hospital Thrombosis Committee department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines as well as complications arising from VTE.

Results

A total of 586 patients were included in this audit. Compliance with VTE pharmacological prophylaxis was recorded, as well as weight-bearing status advised postoperatively. Compliance with prophylaxis in patients who were non-weight-bearing postoperatively was 54.8%. There were three cases of recorded VTE; however, in all cases, appropriate VTE prophylaxis has been prescribed.

Conclusion

Increasing hospital-wide awareness and education of VTE and the fatal complications is imperative. All patients should be administered VTE prophylaxis as an inpatient and on discharge if their weight-bearing status is affected following lower limb orthopaedic surgery. Although our compliance rate for prescription of VTE prophylaxis did not achieve the standards set by NICE, all cases of recorded VTE had been correctly prescribed VTE prophylaxis on discharge. 

Rational and design of the China Pulmonary Thromboembolism Registry Study (CURES): A prospective multicenter registry

BACKGROUND

Epidemiological data on pulmonary embolism (PE) in China needs to be updated and reported. The China Pulmonary Thromboembolism Registry Study (CURES) is designed to provide the cross-sectional spectrum and chronological trends of PE in China, as well as to reveal the intrinsic etiology and pathogenesis of the disease.

METHODS AND DESIGN

The CURES is an ongoing large prospective multicenter registry, which was originally initiated in January 2009 via enrolling suspected or confirmed PE or PE with DVT (deep venous thrombosis) patients and assessed their in-hospital outcomes. As of July 2011, in order to determine the PE-relevant short-term outcomes, enrolled participants were followed-up for at least three months in a longitudinal manner. Since August 2016, with the launch and development of precision medicine research scheme in China, the main principle investigators of CURES decided to collect enrolled patients' blood samples with regular follow-ups every three or six months for at least two years (for long-term outcomes). Up to 31 December 2019, the CURES has enrolled 14,937 eligible patients and collected 1500 blood samples of patients from 100 medical centers in the China PE-DVT network. The study protocol has been approved by the China-Japan Friendship Hospital ethics committee, and all collaborating centers received approvals from their local ethics committee. All patients provided written or verbal informed consent to their participation.

CONCLUSIONS

Findings of the CURES will be valuable for revealing the natural history of PE, and facilitating better disease management in China. Registration Number inClinicalTrials.gov:NCT02943343.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery

BACKGROUND

In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis.

METHODS

Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control.

RESULTS

In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009).

CONCLUSION

In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

Meta-Analysis of Prevalence and Short-Term Prognosis of Hemodynamically Unstable Patients With Symptomatic Acute Pulmonary Embolism

There remains limited information about the prevalence and outcomes of hemodynamic unstable patients with acute pulmonary embolism (PE). We performed a systematic review and meta-analysis of prospective registries that enrolled patients with acute PE to assess the prevalence and prognostic significance of hemodynamic instability for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We also assessed the association between use of thrombolytic therapy versus no use and short-term outcomes in the subgroup of unstable patients. We used a random-effects model to pool study results; and I² testing to assess for heterogeneity. The authors' search retrieved 4 studies that enrolled 1,574 patients with unstable PE (1,574/40,363; 3.9%; 95% confidence interval [CI], 3.7% to 4.1%). Hemodynamic instability had a significant association with short-term all-cause mortality (odds ratio [OR], 5.9; 95% CI, 2.7 to 13.0; I² = 94%), and with PE-related death (OR, 8.2; 95% CI, 3.4 to 19.7). In unstable patients, thrombolytic therapy was associated with reduced odds of short-term all-cause mortality (OR, 0.69; 95% CI, 0.49 to 0.95), and PE-related death (OR, 0.66; 95% CI, 0.45 to 0.97). In conclusion, hemodynamic instability significantly increased the risk of death shortly after PE diagnosis. Use of thrombolytic therapy was associated with significantly reduced short-term mortality.

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.

Predictors of thromboprophylaxis in hospitalised medical patients

Both, underuse and overuse of thromboprophylaxis in hospitalised medical patients is common. We aimed to explore clinical factors associated with the use of pharmacological or mechanical thromboprophylaxis in acutely ill medical patients at high (Geneva Risk Score ≥ 3 points) vs low (Geneva Risk Score < 3 points) risk of venous thromboembolism. Overall, 1,478 hospitalised medical patients from eight large Swiss hospitals were enrolled in the prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study. The study is registered on ClinicalTrials. gov, number NCT01277536. Thromboprophylaxis increased stepwise with increasing Geneva Risk Score (p< 0.001). Among the 962 high-risk patients, 366 (38 %) received no thromboprophylaxis; cancer-associated thrombocytopenia (OR 4.78, 95 % CI 2.75–8.31, p< 0.001), active bleeding on admission (OR 2.88, 95 % CI 1.69–4.92, p< 0.001), and thrombocytopenia without cancer (OR 2.54, 95 % CI 1.31–4.95, p=0.006) were independently associated with the absence of prophylaxis. The use of thromboprophylaxis declined with increasing severity of thrombocytopenia (p=0.001). Among the 516 low-risk patients, 245 (48 %) received thromboprophylaxis; none of the investigated clinical factors predicted its use. In conclusion, in acutely ill medical patients, bleeding and thrombocytopenia were the most important factors for the absence of thromboprophylaxis among highrisk patients. The use of thromboprophylaxis among low-risk patients was inconsistent, without clearly identifiable predictors, and should be addressed in further research.

Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism

There is a need to validate risk assessment tools for hospitalised medical patients at risk of venous thromboembolism (VTE). We investigated whether a predefined cut-off of the Geneva Risk Score, as compared to the Padua Prediction Score, accurately distinguishes low-risk from high-risk patients regardless of the use of thromboprophylaxis. In the multicentre, prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study, 1,478 hospitalised medical patients were enrolled of whom 637 (43%) did not receive thromboprophylaxis. The primary endpoint was symptomatic VTE or VTE-related death at 90 days. The study is registered at ClinicalTrials.gov, number NCT01277536. According to the Geneva Risk Score, the cumulative rate of the primary endpoint was 3.2% (95% confidence interval [CI] 2.2–4.6%) in 962 high-risk vs 0.6% (95% CI 0.2–1.9%) in 516 low-risk patients (p=0.002); among patients without prophylaxis, this rate was 3.5% vs 0.8% (p=0.029), respectively. In comparison, the Padua Prediction Score yielded a cumulative rate of the primary endpoint of 3.5% (95% CI 2.3–5.3%) in 714 high-risk vs 1.1% (95% CI 0.6–2.3%) in 764 lowrisk patients (p=0.002); among patients without prophylaxis, this rate was 3.2% vs 1.5% (p=0.130), respectively. Negative likelihood ratio was 0.28 (95% CI 0.10–0.83) for the Geneva Risk Score and 0.51 (95% CI 0.28–0.93) for the Padua Prediction Score. In conclusion, among hospitalised medical patients, the Geneva Risk Score predicted VTE and VTE-related mortality and compared favourably with the Padua Prediction Score, particularly for its accuracy to identify low-risk patients who do not require thromboprophylaxis.

Clinical practice guidelines for prophylaxis of venous thomboembolism in cancer patients

Symptomatic venous thromboembolism (VTE) occurs 4-7 times more frequently in cancer patients as compared to non-cancer patients. A significant number of risk factors, which can be subcategorised as patient-, cancer- or treatment-related, have been shown to influence the risk of VTE during malignancy and further incorporated in risk-assessment models. Safe and efficient thromboprophylaxis regimens allow substantial decreased in VTE rates, since VTE is most often a largely preventable disease, but thromboprophylaxis remains underused in cancer compared to non-cancer patients. If thromboprophylaxis is warranted in cancer patients undergoing surgery or hospitalised for acute medical illness or with a lower mobility in the absence of contraindications to anticoagulants, its benefit remains controversial in outpatients and may be limited to locally advanced or metastatic pancreatic or lung cancer treated with chemotherapy. The International Initiative on Thrombosis and Cancer-CME free mobile app (ios and android), based on the International Clinical Practice Guidelines (CPG), facilitates their implementation and dissemination of knowledge worldwide so as to improve VTE treatment and prophylaxis in cancer patients.

Assessing the risk for development of Venous Thromboembolism (VTE) in surgical patients using Adapted Caprini scoring system

AIM

To determine the incidence, morbidity and mortality due to Venous Thromboembolism (VTE) in surgical patients, and to assess the validity and reliability of Adapted Caprini scoring in risk stratification for VTE prophylaxis.

METHODOLOGY

This was a prospective observational study in a tertiary care hospital of South India on patients who underwent both elective and emergency surgeries over a period of 9 months. An Adapted Caprini score was devised which included only the clinical criteria. The patients were scored by two persons independently at admission and followed up till the 30th post-operative day and primary and secondary end points were statistically analyzed.

RESULTS

Three hundred and one patients were included and the overall incidence of VTE at 30 days was 7.3%. The risk of developing VTE was found to be significantly higher among the >8 score group as compared to 3-4 group (OR = 153.5, p < 0.001), or the 5-6 group (OR = 52.9, p < 0.001) or the 7-8 group (OR = 2.3, p = 0.002). Patients with a score of 7-8 were more likely to develop VTE as compared to 3-4 group (OR = 67.5, p < 0.001) or the 5-6 group (OR = 23.2, p < 0.001).

CONCLUSION

The risk of developing VTE is less significant in the 5-6 score group compared to 7-8 or more score group. Further stratification of the highest risk groups is recommended to provide appropriate prophylaxis only to the patients with high scores, thereby reducing complications due to VTE prophylaxis.

Venous thromboembolism: identifying patients at risk and establishing prophylaxis

Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants.

Validation of the Caprini risk assessment model for venous thromboembolism in high-risk surgical patients in the background of standard prophylaxis

OBJECTIVE

We used the Caprini venous thromboembolism risk assessment score to prospectively evaluate if there was a correlation between the Caprini scores and the incidence of postoperative deep vein thrombosis (DVT) in high-risk surgical patients. A second objective was to determine whether patients at extremely high risk need a more effective prophylactic regimen.

METHODS

This prospective multicenter observational study involved 140 high-risk patients who underwent abdominal (48%) or cranial and/or spinal (52%) surgery. All patients were assessed using the Caprini model and had a mean score of 9.5 ± 2.7 (range, 5-15). Our standard prophylaxis for venous thromboembolism consisted of above-knee graduated compression stockings with 18 to 21 mm Hg pressure and subcutaneous low-dose unfractionated heparin three times per day, starting on the first or second through the fifth postoperative day depending on the risk of bleeding. We performed a duplex ultrasound examination at baseline during the first 12 to 24 hours after surgery and then every 3 to 5 days until discharge to assess the lower limb venous system up to the inferior vena cava. The end point of the study was ultrasound verification of fresh DVT or pulmonary embolism (PE). Verification of PE was made in all cases of DVT using echocardiography, lung scintigraphy, combined single-photon emission computed tomography and X-ray computed tomography, or autopsy.

RESULTS

Fresh postoperative DVT was found in 39 patients (28%). The incidence of DVT was 2% in patients with a Caprini score of 5 to 8, 26% in patients with scores of 9 to 11, and 65% in patients with scores of 12 to 15 (P for trend < .01). The risk for DVT was increased 18.7-fold for patients with scores of 9 to 11 and 98.4-fold for scores of 12 to 15 compared with patients with scores of 5 to 8. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval, 0.81-0.94) and a Caprini score of 11 was the cutoff point that provided the highest sensitivity combined with highest specificity. In the 77 patients with a score of <11, DVT occurred in 2 patients (3%). In contrast, in the 63 patients with a score of ≥ 11, DVT occurred in 37 patients (59%; P < .01). PE was found in 13 patients (9%) and confirmed with autopsy. In all cases, verified fresh DVT was the source of embolism.

CONCLUSIONS

There was a significant correlation between Caprini scores and the incidence of postoperative DVT in high-risk surgical patients. A Caprini score of ≥ 11 can identify a subgroup of patients at extremely high risk. These patients need a more effective prophylactic regimen.

Implementing thrombosis guidelines in cancer patients: a review

Venous thromboembolism is a frequent and serious complication in patients with cancer. It is an independent prognostic factor of death in cancer patients and the second leading cause of death, but physicians often underestimate its importance, as well as the need for adequate prevention and treatment. Management of venous thromboembolism in patients with cancer requires the coordinated efforts of a wide range of clinicians, highlighting the importance of a multidisciplinary approach. However, a lack of consensus among various national and international clinical practice guidelines has contributed to knowledge and practice gaps among practitioners, and inconsistent approaches to venous thromboembolism. The 2013 international guidelines for thrombosis in cancer have sought to address these gaps by critically re-evaluating the evidence coming from clinical trials and synthesizing a number of guidelines documents. An individualized approach to prophylaxis is recommended for all patients.

Prior myocardial infarction and presence of upper gastrointestinal conditions among patients with venous thromboembolism: prevalence, associated comorbidities and burden

WHAT IS KNOWN AND OBJECTIVES

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious, life-threatening condition that often complicates treatment of individuals who are already ill and increases in risk with age. The comorbidity burden of VTE can complicate treatment; therefore, treatment should be influenced by the presence of comorbidities (Kearon 2012). The prevalence of common conditions in the VTE population is, therefore, an important subject of research. Prevalence of two common comorbid burdens, prior myocardial infarction (MI) and upper gastrointestinal (GI) conditions, was studied among survey respondents who reported DVT or PE.

METHODS

Responses to the 2010 wave of the National Health and Wellness Survey (NHWS), a self-administered, internet-based questionnaire from a nationwide, demographically representative sample of adults, were evaluated.

RESULTS AND DISCUSSION

Among the 814 participants reporting a history of VTE, 9·7% (n = 60) of the DVT subpopulation and 13·2% (n = 39) of the PE subpopulation also reported prior MI. In respondents with prior MI, cardiovascular, urological, and pain comorbidities were each reported as additional comorbidities by at least two thirds of respondents in both the PE and DVT subpopulations, with cardiovascular and urological conditions reported significantly (P < 0·05) more often than among respondents with no prior MI. Among the respondents reporting VTE, 48·9% (n = 302) of the subpopulation reporting DVT and 52·2% (n = 154) of those reporting PE also reported upper GI comorbidities. Cardiovascular and pain conditions in the respondents reporting upper GI comorbidities were each reported by more than three quarters of VTE patients in both the DVT and PE subpopulations and were significantly more common (P < 0·05) than among their counterparts without upper GI comorbidities.

WHAT IS NEW AND CONCLUSION

The results of the NHWS indicate that VTE patients who have either of two common comorbid burdens, prior MI and concomitant upper GI conditions, also showed high levels of additional, concurrent comorbidities and generally poor health status. Clinicians must be aware of the total comorbidity profile of their patients who have experienced VTE in order to best manage them and prescribe appropriate therapy.

Validation of a venous thromboembolism risk assessment model in hospitalized chinese patients: a case-control study

AIM

The appropriate selection of hospitalized patients for venous thromboembolism(VTE) prophylaxis is an important unresolved issue. We sought to validate the Caprini model, a famous individual VTE risk assessment model(RAM), in hospitalized Chinese patients.

METHODS

We performed a retrospective case-control study among unselected hospitalized patients admitted to a comprehensive hospital in China. A total of 347 patients were confirmed to have VTE during hospitalization, and 651 controls were randomly selected to match the patients according to medical service. Both the patients and controls were retrospectively assessed for the risk of VTE using the Caprini RAM.

RESULTS

The average Caprini cumulative risk score in the patients was significantly higher than that observed in the controls(4.69±2.58 vs 3.16±1.82, p＜0.0001). Compared with that observed in the low-risk group, a classification of high-risk according to the Caprini model was associated with a 1.65-fold increased risk of VTE(95%CI 1.05-2.61), while that of highest-risk was associated with a 4.84-fold increased risk of VTE(95%CI 3.06-7.64). After further stratifying the highest risk level with a cumulative risk score of ≥5 into scores of 5-6, 7-8 and ≥9, the patients with a score of 5-6 were found to exhibit a 3.33-fold increased risk of VTE(95%CI 2.06-5.40), those with a score 7-8 exhibited a 9.41-fold increased risk of VTE(95%CI 4.90-18.08) and those with a score of ≥9 exhibited a 24.69-fold(95%CI 7.98-76.40) increased risk of VTE compared with their low-risk counterparts.

CONCLUSIONS

Our study suggests that the Caprini RAM can be used to effectively stratify hospitalized Chinese patients into VTE risk categories based on individual risk factors. The classification of the highest risk level with a cumulative risk score of ≥5 provided significantly more clinical information, and further stratification of this group of patients is needed.

Validation of the Caprini risk assessment model in Chinese hospitalized patients with venous thromboembolism

INTRODUCTION

Venous thromboembolism (VTE) occurs frequently in at-risk hospitalized patients, and prophylaxis of VTE is significantly underused. We sought to preliminarily assess the validity of Caprini risk assessment model, a famous individual VTE risk assessment model, in Chinese hospitalized patients with VTE.

MATERIALS AND METHODS

We undertook a retrospective study combined with a follow-up study among 347 confirmed VTE patients from a Chinese hospital.

RESULTS

Compared with the other two risk assessment models (RAMs), Caprini model can classify much more VTE patients into high or highest risk level and the differences were statistically significant (Caprini model vs Kucher model, p<0.0001; Caprini model vs the Padua Prediction Score, p<0.0001). Caprini model exhibited much more effect at assessing patient's VTE risk among surgical patients than nonsurgical patients(average risk score, 5.71 ± 2.54 vs 4.36 ± 2.51, p<0.0001; by Wilcoxon rank sum test, p=0.001 in favor of the prediction effect of the RAM in surgical patients). Kaplan-Meier analysis showed that patients classified into low and highest risk level by Caprini model had increased hazard for VTE recurrence when compared with patients classified into moderate and high risk level, but the result was not statistically significant (p=0.222).

CONCLUSIONS

Our study preliminarily suggests that the Caprini risk assessment model is a practical and effective tool to assess the risk of VTE among unselected Chinese inpatients and may also be useful in predicting the risk of VTE recurrence. However, future studies with control group and prospective validation of the model in Chinese inpatients are needed.

How to improve the implementation of guidelines on cancer-related thrombosis

Venous thromboembolism (VTE; defined by deep-vein thrombosis, central venous catheter-related thrombosis or pulmonary embolism) is a major therapeutic issue in cancer patients. VTE is reported in 15-20% of patients with cancer and is an independent prognostic factor and a leading cause of death. In this population, low-molecular-weight heparins have been shown to be superior to vitamin K antagonists. The Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the French 'Institut National du Cancer', the European Society of Medical Oncology and the American College of Chest Physicians have all published specific guidelines, but their implementation is still low in clinical practice. Methodological assessment of these guidelines was performed using the Appraisal of Guidelines Research & Evaluation Instrument. None of the guidelines on thrombosis and cancer have sought for patients' preferences, nor were they tested among target users. VTE in cancer patients requires a multidisciplinary approach but downstream of the guidelines publication, the potential organisational barriers in applying the recommendations have not been discussed. Tolerance and cost-effectiveness of long-term use of low-molecular-weight heparin may account for the large heterogeneity seen in daily clinical practice. Homogenization of guidelines in international consensus working groups followed by educational and active implementation strategies would be very valuable in order to improve the care of VTE in cancer patients.

Lessons from French National Guidelines on the treatment of venous thrombosis and central venous catheter thrombosis in cancer patients

Increased prevalence of Venous thromboembolism (VTE), as defined by deep-vein thrombosis (DVT), central venous catheter (CVC) related thrombosis or pulmonary embolism (PE) in cancer patients has become a major therapeutic issue. Considering the epidemiology and each national recommendations on the treatment of VTE in cancer patients, we analysed guidelines implementation in clinical practice. Thrombosis is the second-leading cause of death in cancer patients and cancer is a major risk factor of VTE, due to activation of coagulation, use of long-term CVC, the thrombogenic effects of chemotherapy and anti-angiogenic drugs. Three pivotal trials (CANTHANOX, LITE and CLOT) and several meta-analysis led to recommend the long term (3 to 6 months) use of LMWH during for treating VTE in cancer patients with a high level of evidence. The Italian Association of Medical Oncology (AIOM), the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), the French "Institut National du Cancer" (INCa), the European Society of Medical Oncology (ESMO) and the American College of Chest Physicians (ACCCP) have published specific guidelines for health care providers regarding the prevention and treatment of cancer-associated VTE. Critical appraisal of these guidelines, difficulties in implementation of prophylaxis regimen, tolerance and cost effectiveness of long term use of LMWH may account for large heterogenity in daily clinical practice. Homogenization of these guidelines in international consensus using an adapted independent methodological approach followed by educational and active implementation strategies at each national level would be very valuable to improve the care of VTE in cancer patients.

Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems

BACKGROUND

The adequacy of thromboprophylaxis prescriptions in acutely ill hospitalized medical patients needs improvement.

OBJECTIVE

To prospectively assess the efficacy of thromboprophylaxis adequacy of various clinical decision support systems (CDSS) with the aim of increasing the use of explicit criteria for thromboprophylaxis prescription in nine Swiss medical services.

METHODS

We randomly assigned medical services to a pocket digital assistant program (PDA), pocket cards (PC) and no CDSS (controls). In centers using an electronic chart, an e-alert system (eAlerts) was developed. After 4 months, we compared post-CDSS with baseline thromboprophylaxis adequacy for the various CDSS and control groups.

RESULTS

Overall, 1085 patients were included (395 controls, 196 PC, 168 PDA, 326 eAlerts), 651 pre- and 434 post-CDSS implementation: 472 (43.5%) presented a risk of VTE justifying thromboprophylaxis (31.8% pre, 61.1% post) and 556 (51.2%) received thromboprophylaxis (54.2% pre, 46.8% post). The overall adequacy (% patients with adequate prescription) of pre- and post-CDSS implementation was 56.2 and 50.7 for controls (P = 0.29), 67.3 and 45.3 for PC (P = 0.002), 66.0 and 64.9 for PDA (P = 0.99), 50.5 and 56.2 for eAlerts (P = 0.37), respectively, eAlerts limited overprescription (56% pre, 31% post, P = 0.01).

CONCLUSION

While pocket cards and handhelds did not improve thromboprophylaxis adequacy, eAlerts had a modest effect, particularly on the reduction of overprescription. This effect only partially contributes to the improvement of patient safety and more work is needed towards institution-tailored tools.

Thromboprophylaxis in the intensive care unit: focus on medical-surgical patients

Critically ill patients in the medical-surgical intensive care unit are at high risk for deep venous thrombosis and pulmonary embolism, which comprise venous thromboembolism. Herein, we describe the prevalence, incidence, risk factors, clinical consequences, prophylaxis against venous thromboembolism in critically ill patients, and compliance with thromboprophylaxis. We focus primarily on medical-surgical intensive care unit patients, who represent the largest subgroup of critically ill patients. Despite the large and growing number of critically ill patients in our aging society, their high risk for venous thromboembolism, and the morbidity and mortality associated with this complication of critical illness, relatively few rigorous studies are available. Large, well-designed, randomized trials of thromboprophylaxis, powered to detect differences in patient-important outcomes, are required to advance our understanding and care of these vulnerable patients. Furthermore, because thromboprophylaxis is a common error of omission in hospitalized patients, redoubled efforts are needed to ensure that it is used in practice.

Lack of prophylaxis before the onset of acute venous thromboembolism among hospitalized cancer patients: the SWIss Venous ThromboEmbolism Registry (SWIVTER)

BACKGROUND

Venous thromboembolism (VTE) prophylaxis remains underutilized, particularly in cancer patients. We explored clinical predictors of prophylaxis in hospitalized cancer patients before the onset of acute VTE.

METHODS

In the SWiss Venous ThromboEmbolism Registry, 257 cancer patients (61 +/- 15 years) with acute VTE and prior hospitalization for acute medical illness or surgery within 30 days (91% were at high risk with Geneva VTE risk score > or =3) were enrolled.

RESULTS

Overall, 153 (60%) patients received prophylaxis (49% pharmacological and 21% mechanical) before the onset of acute VTE. Outpatient status at the time of VTE diagnosis [odds ratio (OR) 0.31, 95% confidence interval (CI) 0.18-0.53], ongoing chemotherapy (OR 0.51, 95% CI 0.31-0.85), and recent chemotherapy (OR 0.53, 95% CI 0.32-0.88) were univariately associated with the absence of VTE prophylaxis. In multivariate analysis, intensive care unit admission within 30 days (OR 7.02, 95% CI 2.38-20.64), prior deep vein thrombosis (OR 3.48, 95% CI 2.14-5.64), surgery within 30 days (OR 2.43, 95% CI 1.19-4.99), bed rest >3 days (OR 2.02, 95% CI 1.08-3.78), and outpatient status (OR 0.38, 95% CI 0.19-0.76) remained the only independent predictors of thromboprophylaxis.

CONCLUSIONS

Although most hospitalized cancer patients were at high risk, 40% did not receive any prophylaxis before the onset of acute VTE. There is a need to improve thromboprophylaxis in cancer patients, particularly in the presence of recent or ongoing chemotherapy.

Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patients

BACKGROUND

Worldwide, more than half of the hospitalized medical patients at high risk do not receive venous thromboembolism (VTE) prophylaxis. Although VTE among hospitalized patients at risk is reduced with electronic alerts (eAlerts), the majority of eAlerts are being ignored by the responsible physician.

METHODS

We investigated physician compliance with an advanced eAlert system in 1027 (age 59 +/- 17 years) hospitalized medical patients. A continuously flashing non-interruptive eAlert, visible to all healthcare professionals, was issued in the electronic patient chart 6 h after admission if the physician did not order prophylaxis.

RESULTS

The rate of appropriate prophylaxis increased from 44% before to 76% after the implementation of the eAlert system. Although the patients whose physicians cared for > or = 20 patients during the study period had a more frequent physician response to the eAlert than patients whose physicians cared for fewer patients (69% vs. 40%, P < 0.001), they received appropriate prophylaxis less often (72% vs. 81%, P = 0.016). After adjustment for significant patient predictors of appropriate prophylaxis, including cancer, age, duration of hospital stay, and thrombocytopenia, patients whose physicians cared for > or = 20 patients during the study period were less likely to receive appropriate prophylaxis (odds ratio 0.65, 95% confidence interval 0.44-0.96; P = 0.032) than patients whose physicians cared for fewer patients.

CONCLUSIONS

The introduction of an advanced eAlert system accompanied by continuing medical education for the prevention of VTE resulted in a substantial increase in the rate of appropriate prophylaxis among hospitalized medical patients. However, many eAlerts may cause decreased physician compliance owing to 'alert fatigue'.

Prevention of venous thromboembolism: a key patient safety priority

It is more than 50 years since the first publication of a study showing that symptomatic and fatal venous thromboembolism could be reduced with the use of thromboprophylaxis. Furthermore, it is 23 years since the first evidence-based guidelines recommended routine use of thromboprophylaxis for most hospitalized patients. However, despite the overwhelming evidence that thromboprophylaxis safely and inexpensively reduces thromboembolic complications associated with acute illness and surgery, there continue to be large gaps in the provision of this key patient safety intervention and even larger gaps in the provision of optimal thromboprophylaxis. The implementation of quality improvement strategies, both at the national level and in local hospitals, are able to increase awareness of thromboembolic risks, to increase adherence to thromboprophylaxis guidelines, and to decrease both clinically important thromboembolic events and hospital costs. Therefore, the objective is for every hospitalized patient to receive appropriate thromboprophylaxis based on their thromboembolic and bleeding risks.