A Survey of Physicians' Knowledge and Management of Venous Thromboembolism

Appropriateness of Pharmacologic Prophylaxis against Deep Vein Thrombosis in Medical Wards of an Ethiopian Referral Hospital

BACKGROUND

Most of hospitalized patents are at risk of developing deep vein thrombosis (DVT). The use of pharmacological prophylaxis significantly reduces the incidence of thromboembolic events in high risk patients. The aim of this study was to assess appropriateness of DVT prophylaxis in hospitalized medical patients in an Ethiopian referral hospital.

METHODS

Cross-sectional study design was employed. Patients with a diagnosis of DVT, taking anticoagulant therapy, and those who refused to participate were excluded from the study. Two hundred and six patients were included in the study using simple random sampling method. Modified Padua Risk Assessment Model was used to determine the risk of thromboembolism. SPSS (version 21) was used for analysis.

RESULT

The total risk score for the study subjects ranged from 0 to 11 with a mean score of 3.41 ± 2.55. Nearly half (47.6%) of study participants had high risk to develop thromboembolism. Thrombocytopenia (platelets < 50 billion/L) or coagulopathy, active hemorrhage, and end stage liver disease (INR > 1.5) were the frequently observed absolute contraindications that potentially prevent patients from receiving thromboprophylaxis. Thromboprophylaxis use in nearly one-third (31.6%) of patients admitted in the medical ward of UoGRH was irrational. Patients who had high risk for thromboembolism are more likely to be inappropriately managed for their risk of thromboembolism and patients with thrombocytopenia or coagulopathy were more likely to be managed appropriately.

CONCLUSION

There is underutilization of pharmacologic thromboprophylaxis in medical ward patients. Physicians working there should be aware of risk factors for DVT and indications for pharmacologic thromboprophylaxis and should adhere to guideline recommendations.

Clinicians' knowledge and practices regarding family planning and intrauterine devices in China, Kazakhstan, Laos and Mexico

BACKGROUND

It is widely agreed that the practices of clinicians should be based on the best available research evidence, but too often this evidence is not reliably disseminated to people who can make use of it. This "know-do" gap leads to ineffective resource use and suboptimal provision of services, which is especially problematic in low- and middle-income countries (LMICs) which face greater resource limitations. Family planning, including intrauterine device (IUD) use, represents an important area to evaluate clinicians' knowledge and practices in order to make improvements.

METHODS

A questionnaire was developed, tested and administered to 438 individuals in China (n = 115), Kazakhstan (n = 110), Laos (n = 105), and Mexico (n = 108). The participants responded to ten questions assessing knowledge and practices relating to contraception and IUDs, and a series of questions used to determine their individual characteristics and working context. Ordinal logistic regressions were conducted with knowledge and practices as dependent variables.

RESULTS

Overall, a 96 % response rate was achieved (n = 438/458). Only 2.8 % of respondents were able to correctly answer all five knowledge-testing questions, and only 0.9 % self-reported "often" undertaking all four recommended clinical practices and "never" performing the one practice that was contrary to recommendation. Statistically significant factors associated with knowledge scores included: 1) having a masters or doctorate degree; and 2) often reading scientific journals from high-income countries. Significant factors associated with recommended practices included: 1) training in critically appraising systematic reviews; 2) training in the care of patients with IUDs; 3) believing that research performed in their own country is above average or excellent in quality; 4) being based in a facility operated by an NGO; and 5) having the view that higher quality available research is important to improving their work.

CONCLUSIONS

This analysis supports previous work emphasizing the need for improved knowledge and practices among clinicians concerning the use of IUDs for family planning. It also identifies areas in which targeted interventions may prove effective. Assessing opportunities for increasing education and training programs for clinicians in research and IUD provision could prove to be particularly effective.

Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices "often or very often" (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.

Venous Thromboembolism in Cancer Patients Undergoing Major Abdominal Surgery: Prevention and Management

Cancer is an important risk factor for venous thrombosis. Venous thromboembolism is one of the most common complications of cancer and the second leading cause of death in these patients. Recent research has given insight into mechanism and various risk factors in cancer patients which predispose to thromboembolism. The purpose of this review is to summarize the current knowledge on the prophylaxis, diagnosis, and management of venous thromboembolism in these patients.

Assessing healthcare providers' knowledge and practices relating to insecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegal and Tanzania

BACKGROUND

Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, cost-effectiveness and disappointing utilization of insecticide-treated nets (ITNs).

METHODS

This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.

RESULTS

The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14).

CONCLUSIONS

Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.

The current state of practice in the diagnosis of venous thromboembolism at an academic medical center

Evidence-based guidelines for the diagnosis of venous thromboembolism (VTE) have been recommended, yet the adoption of such guidelines into daily practice is unknown. The purpose of this study was to describe the current practices in the diagnosis of VTE. Medical records of 1161 adult patients who underwent lower extremity venous duplex scans (VDS), chest computerized tomographic (CT) angiography, or ventilation and perfusion (V/Q) scans during a 6-month period were retrospectively reviewed in an academic medical center. Patients who were first diagnosed by CT or V/Q scan still underwent a VDS. Nine patients at high risk had incomplete CT scans, yet no further tests were performed. Five pregnant patients had CT scans as the initial test instead of being screened with VDS or V/Q scanning. Inappropriate use of imaging tests was documented. The recommended guidelines of using clinical probability and D-dimer as the initial screening tests for VTE diagnosis were underused.

The use of prophylaxis in patients undergoing diagnostic tests for suspected venous thromboembolism

Objectives

The purpose of this study was to describe the use of pharmacological and mechanical prophylaxis and clinical outcomes of patients undergoing diagnostic tests for suspected venous thromboembolism (VTE).

Methods

The medical records of 660 consecutive inpatients referred for suspected VTE at an academic medical centre were retrospectively reviewed.

Results

Acute VTE was diagnosed in 138 (21%) of the 660 patients; the incidence of deep vein thrombosis and pulmonary embolism was 18–25%, respectively. Only 61% of eligible patients received pharmacological prophylaxis and 43% of patients received mechanical prophylaxis. The incidence of VTE was higher in patients who did not receive pharmacological prophylaxis (30%) compared with patients who did (16%, P value <0.001).

Conclusions

Preventive measures for VTE, including both pharmacological and mechanical prophylaxis, were underutilized in hospitalized patients undergoing diagnostic tests for suspected VTE.

Economic burden of venous thromboembolism in hospitalized patients

Venous thromboembolism, a condition that includes deep vein thrombosis and pulmonary embolism, is a significant medical problem that affects more than 1 million patients each year. In addition to the immense impact of venous thromboembolism on morbidity and mortality, the economic burden of the disease is considerable, costing the health care system in the United States more than $1.5 billion/year. The cost of managing an initial episode of deep vein thrombosis is estimated at $7712-10,804, and for an initial pulmonary embolism event $9566-16,644. Management of acute venous thromboembolism in patients with cancer costs more than $20,000. Although much of the costs of venous thromboembolism are associated with managing the acute event, there are also significant costs associated with its long-term complications such as recurrent venous thromboembolism, postthrombotic syndrome, and pulmonary hypertension. Data from numerous robust clinical trials have demonstrated that with appropriate prophylaxis, many of these venous thromboembolism events can be prevented in both surgical and medical patients. Even though the strong evidence supporting venous thromboembolism prophylaxis spans several decades, a number of large American and global registries have documented very poor use of appropriate venous thromboprophylaxis. Because of increasing regulatory requirements, hospitals nationwide are developing necessary documentation of appropriate venous thromboembolism prophylaxis programs for both surgical and medical patients. Hospitals and clinicians must have a firm understanding of not only the clinical impact but also the economic impact of failing to use appropriate prophylaxis and of the cost-effectiveness of different venous thromboprophylaxis methods.

The NCCN Clinical Practice Guidelines on Venous Thromboembolic Disease: strategies for improving VTE prophylaxis in hospitalized cancer patients

The risk for venous thromboembolism (VTE) is high in hospitalized cancer patients, and is associated with an elevated risk for recurrent thrombosis, bleeding complications, and use of health care resources. Thromboembolism is the second leading cause of death in hospitalized cancer patients. Thromboprophylaxis with unfractionated heparin or low-molecular-weight heparins has been clinically proven to reduce the risk for VTE and improve outcomes. However, VTE prophylaxis continues to be underprescribed in cancer patients. Recognizing the clinical burden of VTE in cancer patients, the National Comprehensive Cancer Network (NCCN) recently released guidelines for VTE prevention and management. These NCCN guidelines recommend evidence-based prophylactic anticoagulant therapy for all patients admitted to hospital with a diagnosis of cancer who do not have contraindications to anticoagulant use. However, there continue to be barriers to the implementation of clinical practice guidelines and appropriate use of VTE prophylaxis. Multifaceted active educational and electronic interventions are necessary to raise awareness and reduce the burden of cancer-associated thrombosis and its attendant consequences.

Use of tumor necrosis factor inhibitors in rheumatoid arthritis: a national survey of practicing United States rheumatologists

OBJECTIVES

To determine the prescribing practices, laboratory monitoring protocols, and perceived barriers of United States rheumatologists in prescribing tumor necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA).

METHODS

A survey questionnaire was mailed to 1970 rheumatologists who were randomly selected from a national sample of 3008 rheumatologists. A one-page non-response questionnaire was mailed to approximately 200 randomly selected non-responding rheumatologists to assess non-response bias.

RESULTS

Two mailings yielded a response rate of 22.3% (428 completed, usable surveys out of 1922 deliverable surveys). Rheumatologists reported using all three agents in patients with moderate RA (82-87%), severe RA (94-96%), and in newly diagnosed and mild RA patients (10-18%). In patients with severe RA who inadequately responded to methotrexate, 91% of rheumatologists reported using a TNF inhibitor with one other disease modifying anti-rheumatic drug. Over 94% of rheumatologists reported switching patients from one TNF inhibitor to a different TNF inhibitor due to inadequate response or side effects. Most rheumatologists (96%) ordered the purified protein derivative test for tuberculosis, with almost 82% conducting this test at baseline. Costs to patients and insurance coverage were perceived as major barriers to prescribing these agents although the perception was slightly lower with infliximab than with adalimumab or etanercept.

CONCLUSIONS

The use of TNF inhibitors is not restricted to patients with moderate and severe RA. Rheumatologists are fairly similar in their utilization of the three TNF inhibitors although some variation exists in terms of laboratory practices and perceived barriers regarding the use of these agents.

Improved use of thromboprophylaxis for deep vein thrombosis following an educational intervention

BACKGROUND

We evaluated venous thromboembolism (VTE) prophylaxis rates in hospitalized medical patients in a teaching hospital, the State University of New York-Downstate Medical Center-University Hospital of Brooklyn, before and after implementation of a multifaceted VTE prophylaxis quality improvement intervention that combined regular education, dissemination of a decision support tool, and regular audit-and-feedback to resident physicians.

METHODS

The charts of 312 hospitalized medical patients were retrospectively reviewed to assess baseline rates of appropriate VTE prophylaxis. Rates of appropriate VTE prophylaxis were then determined 12 and 18 months after implementation of the quality improvement intervention. Data collected included risk factors for VTE, contraindications to anticoagulant prophylaxis, type of VTE prophylaxis prescribed, and whether the prophylaxis was appropriate.

RESULTS

Most of the hospitalized medically ill patients had 3 or more risk factors for VTE. At baseline, the proportion of patients receiving any form of VTE prophylaxis, primarily unfractionated heparin, was 47%. The proportion of patients for whom a physician provided appropriate prophylaxis was 43%. After the intervention, the proportion of patients receiving prophylaxis significantly increased, to 86% at 12 months, and this level was maintained at 18 months. The rate of appropriate prophylaxis increased to 68% and 85% after 12 and 18 months, respectively.

CONCLUSIONS

The proportion of hospitalized medical patients receiving appropriate VTE prophylaxis as recommended by evidence-based guidelines can be increased significantly by combining regular education, a decision support tool, and regular audit-and-feedback.

Improving the diagnostic process for deep vein thrombosis in orthopaedic outpatients

Prompt diagnosis of proximal lower extremity deep vein thrombosis in outpatients is critical because of the risk of pulmonary embolism. Our purpose was to determine the accuracy of orthopaedists' clinical decisions regarding the diagnosis of proximal deep vein thrombosis in outpatients. A nationally representative random sample of 2300 orthopaedists received a survey of six clinical vignettes. They were asked to estimate the probability of proximal lower extremity deep vein thrombosis using defined criteria and to specify their planned diagnostic tests. A clinical decision rule and evidence-based diagnostic test recommendations from the general literature served as the gold standard for comparison. Six-hundred seventy-six (29%) surgeons completed the survey. The orthopaedists' planned diagnostic tests differed from the gold standard, but these differences varied depending on the probability of deep vein thrombosis. For the moderate and high risk vignettes, the diagnostic test recommendations agreed with the gold standard approximately 70% of the time. With the exception of gender, no differences were found between respondents and nonrespondents. Orthopaedists' approach to the diagnosis of deep vein thrombosis in outpatients potentially could be improved by applying a clinical decision rule and current evidence on diagnostic test usage.

Management patterns and outcomes of patients with venous thromboembolism in the usual community practice setting

OBJECTIVE

The objectives of this study were to observe a commercially insured sample diagnosed with a venous thromboembolism (VTE) event and treated postevent with warfarin and to detail the thromboembolic and bleeding outcomes in the time periods during warfarin therapy and after discontinuation of such therapy.

METHODS

This retrospective, observational cohort study used medical, pharmacy, and eligibility data from 2 US health plans. Study inclusion required an inpatient diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE) between January 1, 1998, and December 31, 2000; warfarin, heparin, or low-molecular-weight heparin within 30 days after diagnosis; no VTE diagnosis; and no anticoagulant use for 3 months preceding diagnosis. A random sample of medical charts was abstracted to validate VTE events and collect prothrombin time/international normalized ratio (INR) result data. Recurrent VTE events, bleeding events, and proportion of time within INR range were captured in the postindex VTE event time period. Univariate and multivariate statistical techniques were used to assess outcomes.

RESULTS

A total of 2,090 patients were identified with a newly diagnosed VTE event (DVT only, 1450; PE with or without DVT, 640). Mean (SD) age was 61.7 (16) years; mean (SD) follow-up time after the index diagnosis was 21.3 (10) months. Overall mean (SD) length of warfarin therapy was 6.6 (6) months. During the follow-up period, 224 patients (10.7%) experienced a recurrent VTE event and 122 patients (5.8%) experienced a bleeding event requiring hospitalization. The cumulative incidence of recurrent VTE events over 3 and 6 months was 9.0% and 10.9%, respectively. Using the chart abstraction subset, patients were within the appropriate INR range 37.7% of the time while receiving warfarin.

CONCLUSIONS

Negative outcomes associated with warfarin therapy-recurrent VTE events and bleeding requiring hospitalization-were experienced by 10.7% and 5.8% of patients, respectively. These data suggest that negative outcomes may be more prevalent in usual community medical practice compared with rates observed in the controlled environment of the clinical trial or specialized anticoagulation clinic.