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Kakkos S, Kirkilesis G, Caprini JA, Geroulakos G, Nicolaides A, Stansby G, Reddy DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism. Cochrane Database Syst Rev 2022; 1:CD005258. [PMID: 35089599 PMCID: PMC8796751 DOI: 10.1002/14651858.cd005258.pub4] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND It is generally assumed by practitioners and guideline authors that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), or both. This is the second update of the review first published in 2008. OBJECTIVES The aim of this review was to assess the efficacy of combined intermittent pneumatic leg compression (IPC) and pharmacological prophylaxis compared to single modalities in preventing VTE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 18 January 2021. We searched the reference lists of relevant articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or controlled clinical trials (CCTs) of combined IPC and pharmacological interventions used to prevent VTE compared to either intervention individually. DATA COLLECTION AND ANALYSIS We independently selected studies, applied Cochrane's risk of bias tool, and extracted data. We resolved disagreements by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity. We assessed the certainty of the evidence using GRADE. The outcomes of interest were PE, DVT, bleeding and major bleeding. MAIN RESULTS We included a total of 34 studies involving 14,931 participants, mainly undergoing surgery or admitted with trauma. Twenty-five studies were RCTs (12,672 participants) and nine were CCTs (2259 participants). Overall, the risk of bias was mostly unclear or high. We used GRADE to assess the certainty of the evidence and this was downgraded due to the risk of bias, imprecision or indirectness. The addition of pharmacological prophylaxis to IPC compared with IPC alone reduced the incidence of symptomatic PE from 1.34% (34/2530) in the IPC group to 0.65% (19/2932) in the combined group (OR 0.51, 95% CI 0.29 to 0.91; 19 studies, 5462 participants, low-certainty evidence). The incidence of DVT was 3.81% in the IPC group and 2.03% in the combined group showing a reduced incidence of DVT in favour of the combined group (OR 0.51, 95% CI 0.36 to 0.72; 18 studies, 5394 participants, low-certainty evidence). The addition of pharmacological prophylaxis to IPC, however, increased the risk of any bleeding compared to IPC alone: 0.95% (22/2304) in the IPC group and 5.88% (137/2330) in the combined group (OR 6.02, 95% CI 3.88 to 9.35; 13 studies, 4634 participants, very low-certainty evidence). Major bleeding followed a similar pattern: 0.34% (7/2054) in the IPC group compared to 2.21% (46/2079) in the combined group (OR 5.77, 95% CI 2.81 to 11.83; 12 studies, 4133 participants, very low-certainty evidence). Tests for subgroup differences between orthopaedic and non-orthopaedic surgery participants were not possible for PE incidence as no PE events were reported in the orthopaedic subgroup. No difference was detected between orthopaedic and non-orthopaedic surgery participants for DVT incidence (test for subgroup difference P = 0.19). The use of combined IPC and pharmacological prophylaxis modalities compared with pharmacological prophylaxis alone reduced the incidence of PE from 1.84% (61/3318) in the pharmacological prophylaxis group to 0.91% (31/3419) in the combined group (OR 0.46, 95% CI 0.30 to 0.71; 15 studies, 6737 participants, low-certainty evidence). The incidence of DVT was 9.28% (288/3105) in the pharmacological prophylaxis group and 5.48% (167/3046) in the combined group (OR 0.38, 95% CI 0.21 to 0.70; 17 studies; 6151 participants, high-certainty evidence). Increased bleeding side effects were not observed for IPC when it was added to anticoagulation (any bleeding: OR 0.87, 95% CI 0.56 to 1.35, 6 studies, 1314 participants, very low-certainty evidence; major bleeding: OR 1.21, 95% CI 0.35 to 4.18, 5 studies, 908 participants, very low-certainty evidence). No difference was detected between the orthopaedic and non-orthopaedic surgery participants for PE incidence (test for subgroup difference P = 0.82) or for DVT incidence (test for subgroup difference P = 0.69). AUTHORS' CONCLUSIONS Evidence suggests that combining IPC with pharmacological prophylaxis, compared to IPC alone reduces the incidence of both PE and DVT (low-certainty evidence). Combining IPC with pharmacological prophylaxis, compared to pharmacological prophylaxis alone, reduces the incidence of both PE (low-certainty evidence) and DVT (high-certainty evidence). We downgraded due to risk of bias in study methodology and imprecision. Very low-certainty evidence suggests that the addition of pharmacological prophylaxis to IPC increased the risk of bleeding compared to IPC alone, a side effect not observed when IPC is added to pharmacological prophylaxis (very low-certainty evidence), as expected for a physical method of thromboprophylaxis. The certainty of the evidence for bleeding was downgraded to very low due to risk of bias in study methodology, imprecision and indirectness. The results of this update agree with current guideline recommendations, which support the use of combined modalities in hospitalised people (limited to those with trauma or undergoing surgery) at risk of developing VTE. More studies on the role of combined modalities in VTE prevention are needed to provide evidence for specific patient groups and to increase our certainty in the evidence.
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Affiliation(s)
- Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George Kirkilesis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joseph A Caprini
- NorthShore University HealthSystem, Evanston, Illinois, USA
- Pritzker School of Medicine, Chicago, Illinois, USA
| | - George Geroulakos
- Department of Surgery and Cancer, Imperial College of Science Technology and Medicine, London, UK
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | - Andrew Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Daniel J Reddy
- Department of Surgery, Wayne State University, Detroit, Michigan, USA
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Kolkailah AA, Abdelghaffar B, Nabhan AF, Piazza G. Standard- versus extended-duration anticoagulation for primary venous thromboembolism prophylaxis in acutely ill medical patients. Hippokratia 2021. [DOI: 10.1002/14651858.cd014541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Ahmed A Kolkailah
- Department of Medicine, Division of Cardiovascular Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | | | - Ashraf F Nabhan
- Department of Obstetrics and Gynaecology, Faculty of Medicine; Ain Shams University; Cairo Egypt
| | - Gregory Piazza
- Division of Cardiovascular Medicine; Brigham and Women's Hospital, Harvard Medical School; Boston MA USA
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Trihan JE, Adam M, Jidal S, Aichoun I, Coudray S, Laurent J, Chaussavoine L, Chausserie S, Guillaumat J, Lanéelle D, Perez-Martin A. Performance of the Wells score in predicting deep vein thrombosis in medical and surgical hospitalized patients with or without thromboprophylaxis: The R-WITT study. Vasc Med 2021; 26:288-296. [PMID: 33749393 DOI: 10.1177/1358863x21994672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score's accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% (p = 0.22) and 1.7%, 4.2% and 25.8% (p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.
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Affiliation(s)
- Jean-Eudes Trihan
- Vascular Medicine Department, University Hospital Poitiers, Poitiers, France
| | - Michael Adam
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Sara Jidal
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Isabelle Aichoun
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Sarah Coudray
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Jeremy Laurent
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Laurent Chaussavoine
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Sebastien Chausserie
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Jerome Guillaumat
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Damien Lanéelle
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Antonia Perez-Martin
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
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Abstract
IMPORTANCE Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. OBSERVATIONS PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. CONCLUSIONS AND RELEVANCE Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Moumneh T, Riou J, Douillet D, Henni S, Mottier D, Tritschler T, Le Gal G, Roy PM. Validation of risk assessment models predicting venous thromboembolism in acutely ill medical inpatients: A cohort study. J Thromb Haemost 2020; 18:1398-1407. [PMID: 32168402 DOI: 10.1111/jth.14796] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because hospital-acquired venous thromboembolism (VTE) represents a frequent cause of preventable deaths in medical inpatients, identifying at-risk patients requiring thromboprophylaxis is critical. We aimed to externally assess the Caprini, IMPROVE, and Padua VTE risk scores and to compare their performance to advanced age as a stand-alone predictor. METHODS We performed a retrospective analysis of patients prospectively enrolled in the PREVENU trial. Patients aged 40 years and older, hospitalized for at least 2 days on a medical ward were consecutively enrolled and followed for 3 months. Critical ill patients were not recruited. Patients diagnosed with VTE within 48 hours from admission, or receiving full dose anticoagulant treatment or who underwent surgery were excluded. All suspected VTE and deaths occurring during the 3-month follow-up were adjudicated by an independent committee. The three scores were retrospectively assessed. Body mass index, needed for the Padua and Caprini scores, was missing in 44% of patients. RESULTS Among 14 910 eligible patients, 14 660 were evaluable, of which 1.8% experienced symptomatic VTE or sudden unexplained death during the 3-month follow-up. The area under the receiver operating characteristic curves (AUC) were 0.60 (95% confidence interval [CI] 0.57-0.63), 0.63 (95% CI 0.60-0.66) and 0.64 (95% CI 0.61-0.67) for Caprini, IMPROVE, and Padua scores, respectively. None of these scores performed significantly better than advanced age as a single predictor (AUC 0.61, 95% CI 0.58-0.64). CONCLUSION In our study, Caprini, IMPROVE, and Padua VTE risk scores have poor discriminative ability to identify not critically ill medical inpatients at risk of VTE, and do not perform better than a risk evaluation based on patient's age alone.
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Affiliation(s)
- Thomas Moumneh
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jérémie Riou
- Unité de Formation-Recherche Santé, MINT UMR INSERM 1066, CNRS 6021, Université d'Angers, Angers, France
| | - Delphine Douillet
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
| | - Samir Henni
- Service des explorations fonctionnelles vasculaires, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, Université d'Angers, Angers, France
| | - Dominique Mottier
- Département de Médecine Interne et Pneumologie, CHU de la Cavale Blanche, EA3878 (GETBO), CIC INSERM 1412, InnoVTE F-CRIN, Université de Bretagne Occidentale, Brest, France
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Pierre-Marie Roy
- Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015, UMR INSERM 1083, InnoVTE F-CRIN, Université d'Angers, Angers, France
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Spyropoulos AC, Lipardi C, Xu J, Lu W, Suh E, Yuan Z, Levitan B, Sugarmann C, De Sanctis Y, Spiro TE, Barnathan ES, Raskob GE. Improved Benefit Risk Profile of Rivaroxaban in a Subpopulation of the MAGELLAN Study. Clin Appl Thromb Hemost 2020; 25:1076029619886022. [PMID: 31746218 PMCID: PMC7019408 DOI: 10.1177/1076029619886022] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Acutely ill medical patients are at risk of venous thromboembolism (VTE) and VTE-related
mortality during hospitalization and posthospital discharge, but widespread adoption of
extended thromboprophylaxis has not occurred. We analyzed a subpopulation within the
MAGELLAN study of extended thromboprophylaxis with rivaroxaban to reevaluate the benefit
risk profile. We identified 5 risk factors for major and fatal bleeding after a clinical
analysis of the MAGELLAN study and analyzed efficacy and safety with these patients
excluded (n = 1551). Risk factors included: active cancer, dual antiplatelet therapy at
baseline, bronchiectasis/pulmonary cavitation, gastroduodenal ulcer, or bleeding within 3
months before randomization. We evaluated efficacy, safety, and benefit risk using
clinically comparable endpoints in the subpopulation. At day 10, rivaroxaban was
noninferior to enoxaparin (relative risk [RR] = 0.82, 95% confidence interval [CI] =
0.58-1.15) and at day 35 rivaroxaban was significantly better than enoxaparin/placebo (RR
= 0.68, 95% CI = 0.53-0.88) in reducing VTE and VTE-related death. Major bleeding was
reduced at day 10 (RR = 2.18, 95% CI = 1.07-4.44 vs 1.19, 95% CI = 0.54-2.65) and at day
35 (2.87, 95% CI = 1.60-5.15 vs 1.48, 95% CI = 0.77-2.84) for MAGELLAN versus this
subpopulation, respectively. The benefit risk profile was favorable in this subpopulation
treated for 35 days, with the number needed to treat ranging from 55 to 481 and number
needed to harm from 455 to 1067 for all pairwise evaluations. Five exclusionary criteria
defined a subpopulation of acutely ill medical patients with a positive benefit risk
profile for in-hospital and extended thromboprophylaxis with rivaroxaban.
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Affiliation(s)
- Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, NY, USA
| | | | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Eunyoung Suh
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Yoriko De Sanctis
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | - Theodore E Spiro
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | | | - Gary E Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Freund N, Sabroe JE, Bytzer P, Madsen SM. Compliance with Guidelines on Thromboprophylaxis for Acutely Admitted Medical Patients. Adv Ther 2018; 35:1873-1883. [PMID: 30367365 DOI: 10.1007/s12325-018-0821-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The risk of venous thromboembolism (VTE) is increased by more than 100-fold among hospitalised medical patients compared to subjects in the community. The Danish Council for the Use of Expensive Hospital Medicines has published national guidelines on thromboprophylaxis (TP) in which the risks of VTE and bleeding are balanced. We wanted to investigate the proportion of acutely admitted medical patients for whom thromboprophylaxis was indicated and to what extent the guidelines were followed. METHODS Data from patients hospitalised at two medical wards were screened. We registered the proportion of patients for whom mechanical or pharmacologic TP (MTP and PTP, respectively) was indicated and whether national guidelines were followed. All data extraction and analyses were performed retrospectively. RESULTS After exclusion criteria were applied, 340 cases remained. PTP was indicated in 26 patients (7.6%) but only 4 patients were treated besides 12 patients who were already in anticoagulant treatment at submission. Conversely, 8/306 patients, in whom TP was not indicated, were started on PTP. MTP was indicated in 8/340 patients (2.4%) but therapy was not initiated in any of them. The majority (320/340, 94.1%) of cases was managed in accordance with existing guidelines. However, this high proportion was mainly explained by the large number of untreated patients, where TP was not indicated. CONCLUSION A large proportion of hospitalised medical patients was managed in conflict with national guidelines. A systematic approach to TP in patients with acute medical illness should be implemented. Plain language summary available for this article.
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Affiliation(s)
- Nanna Freund
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
| | - Jonas E Sabroe
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark
| | - Peter Bytzer
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Søren M Madsen
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
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Alper EC, Ip IK, Balthazar P, Piazza G, Goldhaber SZ, Benson CB, Lacson R, Khorasani R. Risk Stratification Model: Lower-Extremity Ultrasonography for Hospitalized Patients with Suspected Deep Vein Thrombosis. J Gen Intern Med 2018; 33:21-25. [PMID: 28916935 PMCID: PMC5756163 DOI: 10.1007/s11606-017-4170-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/25/2017] [Accepted: 08/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Wells score for deep venous thrombosis (DVT) has a high failure rate and low efficiency among inpatients. OBJECTIVE To create and validate an inpatient-specific risk stratification model to help assess pre-test probability of DVT in hospitalized patients. DESIGN Prospective cohort study of hospitalized patients undergoing lower-extremity ultrasonography studies (LEUS) for suspected DVT. Demographics, physical findings, medical history, medications, hospitalization, and laboratory and imaging results were collected. Samples were divided into model derivation (patients undergoing LEUS 11/1/2012-12/31/2013) and validation cohorts (LEUS 1/1/2014-5/31/2015). A DVT prediction rule was derived using the recursive partitioning algorithm (decision tree-type approach) and was then validated. PARTICIPANTS Adult inpatients undergoing LEUS for suspected DVT from November 2012 to May 2015, excluding those with DVT in the prior 3 months, at a 793-bed, urban academic quaternary-care hospital with ~50,000 admissions annually. MAIN MEASURES The primary outcome was the presence of proximal DVT, and the secondary outcome was the presence of any DVT (proximal or distal). Model sensitivity and specificity for predicting DVT were calculated. KEY RESULTS Recursive partitioning yielded four variables (previous DVT, active cancer, hospitalization ≥ 6 days, age ≥ 46 years) that optimized the prediction of proximal DVT and yield in the derivation cohort. From this decision tree, we stratified a scoring system using the validation cohort, categorizing patients into low- and high-risk groups. The incidence rates of proximal DVT were 2.9% and 12.0%, and of any DVT were 5.2% and 21.0%, for the low- and high-risk groups, respectively. The AUC for the discriminatory accuracy of the Center for Evidence-Based Imaging (CEBI) score for risk of proximal DVT identified on LEUS was 0.73. Model sensitivity was 98.1% for proximal and 98.1% for any DVT. CONCLUSIONS In hospitalized adults, specific factors can help clinicians predict risk of DVT, identifying those with low pre-test probability, in whom ultrasonography can be safely avoided.
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Affiliation(s)
- Emily C Alper
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA
| | - Ivan K Ip
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA.
| | - Patricia Balthazar
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA
| | - Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carol B Benson
- Division of Ultrasound, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronilda Lacson
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, USA.,Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Antic D, Jelicic J, Vukovic V, Nikolovski S, Mihaljevic B. Venous thromboembolic events in lymphoma patients: Actual relationships between epidemiology, mechanisms, clinical profile and treatment. Blood Rev 2017; 32:144-158. [PMID: 29126566 DOI: 10.1016/j.blre.2017.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 10/15/2017] [Accepted: 10/27/2017] [Indexed: 02/08/2023]
Abstract
Venous thromboembolic events (VTE) are an underestimated health problem in patients with lymphoma. Many factors contribute to the pathogenesis of thromboembolism and the interplay between various mechanisms that provoke VTE is still poorly understood. The identification of parameters that are associated with an increased risk of VTE in lymphoma patients led to the creation of several risk-assessment models. The models that evaluate potential VTE risk in lymphoma patients in particular are quite limited, and have to be validated in larger study populations. Furthermore, the VTE prophylaxis in lymphoma patients is largely underused, despite the incidence of VTE. The lack of adequate guidelines for the prophylaxis and treatment of VTE in lymphoma patients, together with a cautious approach due to an increased risk of bleeding, demands great efforts to ensure the implementation of current knowledge in order to reduce the incidence and complications of VTE in lymphoma patients.
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Affiliation(s)
- Darko Antic
- Clinic for Hematology, Clinical Centre Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia.
| | - Jelena Jelicic
- Clinic for Hematology, Clinical Centre Serbia, Belgrade, Serbia
| | - Vojin Vukovic
- Clinic for Hematology, Clinical Centre Serbia, Belgrade, Serbia
| | | | - Biljana Mihaljevic
- Clinic for Hematology, Clinical Centre Serbia, Belgrade, Serbia; Medical Faculty, University of Belgrade, Belgrade, Serbia
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Diamantouros A, Kiss A, Papastavros T, U. D, Zwarenstein M, Geerts WH. The TOronto ThromboProphylaxis Patient Safety Initiative (TOPPS): A cluster randomised trial. Res Social Adm Pharm 2017; 13:997-1003. [DOI: 10.1016/j.sapharm.2017.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby G, Reddy DJ, Ntouvas I. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism. Cochrane Database Syst Rev 2016; 9:CD005258. [PMID: 27600864 PMCID: PMC6457599 DOI: 10.1002/14651858.cd005258.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND It is generally assumed by practitioners and guideline authors that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), or both. This is an update of the review first published in 2008. OBJECTIVES The aim of this review was to assess the efficacy of combined intermittent pneumatic leg compression (IPC) and pharmacological prophylaxis versus single modalities in preventing venous thromboembolism. SEARCH METHODS For this update the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (May 2016). In addition the CIS searched the Cochrane Register of Studies (CENTRAL (2016, Issue 4)). Clinical trials databases were searched for details of ongoing or unpublished studies. SELECTION CRITERIA Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of combined IPC and pharmacological interventions used to prevent VTE. DATA COLLECTION AND ANALYSIS We independently selected trials and extracted data. Disagreements were resolved by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity. MAIN RESULTS We included a total of 22 trials (9137 participants) of which 15 were randomized trials (7762 participants). The overall risk of bias was mostly unclear or high due to selection and performance bias. We used GRADE to assess the quality of the evidence and this was downgraded from high to moderate or very low due to the risk of bias, imprecision or indirectness.The rate of PE in the studies comparing IPC alone with combined IPC and pharmacological prophylaxis was low, underpowering the analyses. The incidence of symptomatic PE was 0.79% with IPC, but ranged between 0.1 to 1% with combined IPC and pharmacological prophylaxis (OR 0.49, 95% CI 0.18 to 1.34; 12 studies, 3017 participants, moderate quality evidence). The incidence of DVT was 4.10% in the IPC group and 2.19% in the combined group showing a reduced incidence of DVT in favour of the combined group (OR 0.52, 95% CI 0.33 to 0.82; 11 studies, 2934 participants, moderate quality evidence). The addition of an anticoagulant to IPC, however, increased the risk of any bleeding compared to IPC alone; 0.66% (7/1053) in the IPC group and 4.0% (44/1102) in the combined group (OR 5.04, 95% CI 2.36 to 10.77; 7 studies, 2155 participants, moderate quality evidence). Major bleeding followed a similar pattern; 0.1% (1/1053) in the IPC group to 1.5% (17/1102) in the combined group (OR 6.81, 95% CI 1.99 to 23.28; 7 studies, 2155 participants, moderate quality evidence).We detected no difference between the type of surgery subgroups such as orthopedic and non-orthopedic participants for DVT incidence (P = 0.16). Tests for differences between type of surgery subgroups were not possible for PE incidence.Compared with pharmacological prophylaxis alone, the use of combined IPC and pharmacological prophylaxis modalities reduced the incidence of symptomatic PE from 2.92% to 1.20% (OR 0.39, 95% CI 0.23 to 0.64; 10 studies, 3544 participants, moderate quality evidence). The incidence of DVT was 6.2% in the pharmacological prophylaxis group and 2.9% in the combined group showing no difference between the combined and pharmacological prophylaxis groups (OR 0.42, 95% CI 0.18 to 1.03; 11 studies, 2866 participants, moderate quality evidence). Increased bleeding side effects were not observed for IPC when it was added to anticoagulation (bleeding: OR 0.80, 95% CI 0.30 to 2.14, very low quality evidence; major bleeding: OR 1.21, 95% CI 0.35 to 4.18, very low quality evidence, 3 studies, 244 participants).No difference was detected between the type of surgery subgroups for PE incidence (P = 0.68) or for DVT incidence (P = 0.10). AUTHORS' CONCLUSIONS Moderate quality evidence suggests that combining IPC and pharmacological prophylaxis, compared with IPC or pharmacological prophylaxis alone, decreases the incidence of DVT when compared to compression, and incidence of PE when compared to anticoagulation. Moderate quality evidence suggests that there is no difference between combined and single modalities in the incidence of PE when compared with compression alone and DVT when compared with anticoagulation alone. The quality of evidence for PE or DVT was downgraded to moderate due to imprecision or risk of bias in study methodology, highlighting the need for further research. Moderate quality evidence suggests the addition of pharmacological prophylaxis to IPC, increased the risk of bleeding compared to IPC alone, a side effect not observed for IPC when added to pharmacological prophylaxis (very low quality evidence), as expected for a physical method of thromboprophylaxis. The quality of evidence for bleeding was downgraded to moderate due to indirectness or very low due to risk of bias in study methodology, indirectness and imprecision highlighting the need for further research. Nevertheless, the results of the current review agree with current guideline recommendations, which support the use of combined modalities in hospitalised patients (limited to those with trauma or undergoing surgery) at risk of developing VTE. More studies on the role of combined modalities in VTE prevention are needed.
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Affiliation(s)
- Stavros K Kakkos
- University of Patras Medical SchoolDepartment of Vascular SurgeryHippocrates Ave, RioPatrasAchaiaGreece26504
| | - Joseph A Caprini
- Evanston Northwestern HealthcareDepartment of SurgeryNorthwestern UniversityEvanstonIllinoisUSA60201
| | - George Geroulakos
- Ealing Hospital and Imperial College, LondonVascular Unit and Department of Vascular SurgeryUxbridge RoadSouthallMiddlesexUKUB1 3HW
| | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Centre, Cyprus University2 Kyriacou Matsi StreetAyios DhometiosNicosiaCyprus2368
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
| | - Daniel J Reddy
- Department of SurgeryDivision of Vascular SurgeryHenry Ford Hospital2799 W. Grand BoulevardDetroitMichiganUSA28202
| | - Ioannis Ntouvas
- University Hospital of PatrasVascular SurgeryPatrasGreece26504
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Ongen G, Demir M, Molinas N, Ince B, Ongen Z. Evaluation of the Practice Pattern of Medical Patients’ VTE Prophylaxis With a Standard Risk Assessment Model Form. Clin Appl Thromb Hemost 2015; 21:412-9. [DOI: 10.1177/1076029613505765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hospitalized acutely ill patients face high risk for venous thromboembolism (VTE) unless appropriate thromboprophylaxis is applied. This study aimed to determine VTE prophylaxis practices for inpatients in Turkey and to evaluate the impact of physicians’ training via a modified “Standard Medical Patients’ VTE Risk Assessment Model (MERAM).” A total of 607 inpatients included in this national multicenter noninterventional observational registry were evaluated in terms of demographics, VTE risk, and preventive measures at 2 consecutive cross-sectional visits. Physicians were asked to complete a questionnaire on current VTE method risk assessment and other models including MERAM. The VTE prophylaxis rates significantly increased from 49.4% to 62.4% between visits ( P < .05). The lack of risk evaluation decreased from 74.6% to 19.5% ( P < .001). Percentage of physicians using prophylaxis and use of MERAM increased between visits. Physician training proved effective for providing general “awareness” of VTE prophylaxis and led to higher rates of risk assessment model-based appropriate VTE prophylaxis.
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Affiliation(s)
- Gul Ongen
- Department of Chest Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Muzaffer Demir
- Department of Hematology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Nil Molinas
- Department of Oncology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Birsen Ince
- Department of Neurology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Tsai J, Grant AM, Beckman MG, Grosse SD, Yusuf HR, Richardson LC. Determinants of venous thromboembolism among hospitalizations of US adults: a multilevel analysis. PLoS One 2015; 10:e0123842. [PMID: 25879844 PMCID: PMC4399914 DOI: 10.1371/journal.pone.0123842] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/25/2015] [Indexed: 12/01/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors—demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics—for VTE diagnosis among hospitalizations of US adults. Methods We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals. Results Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions—acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss—was associated independently with 1.04 (95% CI: 1.02−1.06) to 2.91 (95% CI: 2.81−3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%−450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%−15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals. Conclusion The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.
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Affiliation(s)
- James Tsai
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Althea M. Grant
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Michele G. Beckman
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Scott D. Grosse
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Hussain R. Yusuf
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lisa C. Richardson
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Mokhtari M, Attarian H, Norouzi M, Kouchek M, Kashani BS, Sirati F, Pourmirza B, Mir E. Venous thromboembolism risk assessment, prophylaxis practices and interventions for its improvement (AVAIL-ME Extension Project, Iran). Thromb Res 2014; 133:567-73. [PMID: 24507872 DOI: 10.1016/j.thromres.2014.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/29/2013] [Accepted: 01/06/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major health issue worldwide. Data about VTE prophylaxis practices in developing countries are scarce. OBJECTIVES The primary objectives of this survey were to define the VTE risk factors in hospitalized patients, to determine the rates of VTE prophylaxis administration and guideline compliance and to assess the effects of an educational program on VTE prophylaxis practices in Iran. PATIENTS AND METHODS Data on 1219 patients from twenty hospitals in Iran were extracted from the AVAIL-ME Extension project main databank. VTE risks were categorized according to the Caprini Risk Assessment Model. Logistic regression analysis was carried out to assess factors influencing VTE prophylaxis. We also examined the impact of an educational program which consisted of awareness, risk assessment, internal protocol implementation and re-assessment, on VTE prophylaxis practices. RESULTS Of 1219 patients, 789 (65%) and 430 (35%) were surgical and medical, respectively. VTE risks, categorized in low, moderate, high and very high were detected in 14%, 17%, 26% and 43% of patients respectively with a total of 1042(85%) patients being at risk for VTE. Of 882 (85%) eligible patients for VTE prophylaxis, 737 (83.5%) received any drug prophylaxis of whom 265 (62%) were medical and 472 (60%) were surgical. ACCP guidelines compliance was 60% and 33% in surgical and medical patients respectively. Any VTE prevention, drug prophylaxis, mechanical prophylaxis and guideline adherence were, 48% vs. 64%, 45% vs. 60%, 6% vs. 9% and 34% vs. 45% respectively (p<00.1) before and after implementation of the VTE educational program. CONCLUSIONS Despite an overall improvement in VTE prevention, areas such as inappropriate use of VTE prophylaxis in a large number of patients, significant under-use of mechanical devices and guideline adherence require closer attention. VTE awareness education is beneficial in improving VTE prophylaxis in Iran.
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Affiliation(s)
- Majid Mokhtari
- Internal Medicine, Pulmonary and Critical Care Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Hamid Attarian
- Department of Hematology, Shahid Beheshti University of Medical Sciences, Modarres Hospital, Tehran, Iran
| | - Masoud Norouzi
- Department of Orthopedic Surgery, Rasool-E-Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Kouchek
- Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Sharif Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih Daneshvari Hosp., Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Elham Mir
- Sanofi Medical Department, Tehran, Iran
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Zheng H, Liu L, Sun H, Wang X, Wang Y, Zhou Y, Lu J, Zhao X, Wang C, Dong K, Yang Z, Wang Y. Prophylaxis of deep venous thrombosis and adherence to guideline recommendations among inpatients with acute stroke: results from a multicenter observational longitudinal study in China. Neurol Res 2013; 30:370-6. [DOI: 10.1179/174313208x300387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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17
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Piazza G, Anderson FA, Ortel TL, Cox MJ, Rosenberg DJ, Rahimian S, Pendergast WJ, McLaren GD, Welker JA, Akus JJ, Stevens SM, Elliott CG, Freeman AL, Patton WF, Dabbagh O, Wyman A, Huang W, Rao AF, Goldhaber SZ. Randomized trial of physician alerts for thromboprophylaxis after discharge. Am J Med 2013; 126:435-42. [PMID: 23510945 DOI: 10.1016/j.amjmed.2012.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/21/2012] [Accepted: 09/23/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Many hospitalized Medical Service patients are at risk for venous thromboembolism in the months after discharge. We conducted a multicenter randomized controlled trial to test whether a hospital staff member's thromboprophylaxis alert to an Attending Physician before discharge will increase the rate of extended out-of-hospital prophylaxis and, in turn, reduce the incidence of symptomatic venous thromboembolism at 90 days. METHODS From April 2009 to January 2010, we enrolled hospitalized Medical Service patients using the point score system developed by Kucher et al to identify those at high risk for venous thromboembolism who were not ordered to receive thromboprophylaxis after discharge. There were 2513 eligible patients from 18 study sites randomized by computer in a 1:1 ratio to the alert group or the control group. RESULTS Patients in the alert group were more than twice as likely to receive thromboprophylaxis at discharge as controls (22.0% vs 9.7%, P <.0001). Based on an intention-to-treat analysis, symptomatic venous thromboembolism at 90 days (99.9% follow-up) occurred in 4.5% of patients in the alert group, compared with 4.0% of controls (hazard ratio 1.12; 95% confidence interval, 0.74-1.69). The rate of major bleeding at 30 days in the alert group was similar to that of the control group (1.2% vs 1.2%, hazard ratio 0.94; 95% confidence interval, 0.44-2.01). CONCLUSIONS Alerting providers to extend thromboprophylaxis after hospital discharge in Medical Service patients increased the rate of prophylaxis but did not decrease the rate of symptomatic venous thromboembolism.
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Affiliation(s)
- Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Dobesh PP, Trujillo TC, Finks SW. Role of the Pharmacist in Achieving Performance Measures to Improve the Prevention and Treatment of Venous Thromboembolism. Pharmacotherapy 2013; 33:650-64. [DOI: 10.1002/phar.1244] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Paul P. Dobesh
- College of Pharmacy; University of Nebraska Medical Center; Omaha; Nebraska
| | - Toby C. Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora; Colorado
| | - Shannon W. Finks
- College of Pharmacy; University of Tennessee Health Science Center; Memphis; Tennessee
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Goldhaber SZ. Rationale supporting an “opt-out” policy for pharmacological venous thromboembolism prophylaxis in hospitalized medical patients. J Thromb Thrombolysis 2013; 35:371-4. [DOI: 10.1007/s11239-012-0843-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Albertsen IE, Larsen TB, Rasmussen LH, Overvad TF, Lip GYH. Prevention of venous thromboembolism with new oral anticoagulants versus standard pharmacological treatment in acute medically ill patients: a systematic review and meta-analysis. Drugs 2013; 72:1755-64. [PMID: 22876779 DOI: 10.2165/11635630-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common and potentially avoidable cause of morbidity and mortality in patients hospitalized for acute medical illness. OBJECTIVE Our objective was to conduct a systematic review of studies that assessed the efficacy and safety of new oral anticoagulant (OAC) drugs versus standard pharmacological drugs and/or placebo in prevention of VTE in acute medically ill patients. METHODS PubMed.org and ClinicalTrials.gov databases were searched to identify studies that evaluated the efficacy and safety of a new OAC versus the standard pharmacological treatment and/or placebo in the prevention of VTE in medically ill patients. Relative risks (RR), weighted means and 95% CIs were calculated. Statistical heterogeneity was evaluated using Chi2 and I2 statistics. Two studies were included in the meta-analysis. The primary outcome in both studies was the composite of VTE-related death, symptomatic non-fatal pulmonary embolism (PE), symptomatic deep venous thrombosis (DVT) and asymptomatic proximal DVT. Both studies compared a factor (F)Xa inhibitor with enoxaparin in standard short-term thromboprophylaxis followed by a period where the FXa inhibitor was compared with placebo as prolonged thromboprophylaxis in medically ill patients. The primary major safety outcome in both studies was a composite of treatment-related major bleeding and clinically relevant non-major bleeding. A total of 14 629 patients were randomized. RESULTS Compared with subjects treated with enoxaparin followed by placebo, the RR of the primary outcome during the prolonged treatment period was 0.79 (95% CI 0.66, 0.94), the RR for the primary outcome during the first short-term treatment period was 1.03 (95% CI 0.81, 1.31). For major bleeding during the prolonged treatment period, the RR was 2.69 (95% CI 1.65, 4.39) for patients treated with an FXa inhibitor compared with enoxaparin/placebo. For major bleeding during the shorter treatment period, the RR was 2.01 (95% CI 1.10, 3.65) in favour of enoxaparin. CONCLUSION In acute medically ill patients, prolonged thromboprophylaxis with an oral FXa inhibitor is more protective than regular short-term treatment with enoxaparin. However, treatment with FXa inhibitors is significantly associated with major bleeding, both in long- and short-term treatment compared with enoxaparin.
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Affiliation(s)
- Ida Ehlers Albertsen
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Majluf-Cruz A, Castro Martinez G, Herrera Cornejo MA, Liceaga-Cravioto G, Espinosa-Larrañaga F, Garcia-Chavez J. Awareness regarding venous thromboembolism among internal medicine practitioners in Mexico: a national cross-sectional study. Intern Med J 2012; 42:1335-41. [DOI: 10.1111/j.1445-5994.2011.02646.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Accepted: 11/13/2011] [Indexed: 11/27/2022]
Affiliation(s)
- A. Majluf-Cruz
- Medical Research Unit in Thrombosis, Hemostasis, and Atherogenesis; Mexican Institute of Social Security
| | | | | | | | | | - J. Garcia-Chavez
- Clinical Epidemiology Research Unit; UMAE La Raza; Mexican Institute of Social Security; Mexico City Mexico
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Mahan CE, Spyropoulos AC. ASHP Therapeutic Position Statement on the Role of Pharmacotherapy in Preventing Venous Thromboembolism in Hospitalized Patients. Am J Health Syst Pharm 2012; 69:2174-90. [DOI: 10.2146/ajhp120236] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | - Alex C. Spyropoulos
- Division of Hematology/Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
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Basey AJ, Krska J, Kennedy TD, Mackridge AJ. Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study. BMJ Open 2012; 2:e001668. [PMID: 23135540 PMCID: PMC3533008 DOI: 10.1136/bmjopen-2012-001668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 10/03/2012] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Implementing venous thromboembolism (VTE) risk assessment guidance on admission to hospital has proved difficult worldwide. In 2010, VTE risk assessment in English hospitals was linked to financial sanctions. This study investigated possible barriers and facilitators for VTE risk assessment in medical patients and evaluated the impact of local and national initiatives. SETTING Acute Medical Unit in one English National Health Service university teaching hospital. METHODS This was a mixed methods study; National Research Ethics Service approval was granted. Data were collected over four 1-week periods; November 2009 (1), January 2010 (2), April 2010 (3) and April 2011 (4). Case notes for all medical patients admitted during these periods were reviewed. Thirty-six staff were observed admitting 71 of these patients; 24 observed staff participated in a structured interview. RESULTS 876 case notes were reviewed. In total, 82.1% of patients had one or more VTE risk factors and 25.3% one or more bleeding risks. VTE risk assessment rose from a baseline of 6.9-19.6%, following local initiatives, and to 98.7% following financially sanctioned government targets. A similar increase in appropriate prescribing of prophylaxis was seen, but inappropriate prescribing also rose. No staff observed in period 1 conducted VTE risk assessment, risk-assessment forms were largely ignored or discarded during period 2; and electronic recording systems available during period 3 were not accessed. Few patients were asked any VTE-related questions in periods 1, 2 or 3. Interviewees' actual knowledge of VTE risk was not related to perceived knowledge level. Eight of the 24 staff interviewed were aware of national policies or guidance: none had seen them. Principal barriers identified to risk assessment were: involvement of multiple staff in individual admissions; interruptions; lack of policy awareness; time pressure and complexity of tools. CONCLUSIONS National financial sanctions appear effective in implementing guidance, where other local measures have failed.
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Affiliation(s)
- Avril Janette Basey
- Pharmacy Department, Royal Liverpool University Hospital, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Janet Krska
- Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Chatham, Kent, UK
| | - Tom D Kennedy
- Acute Medical Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Adam John Mackridge
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
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Goubran HA, Sholkamy S, El-Haddad A, Mahmoud A, Rizkallah MA, Sobhy G. Venous thromboembolism risk and prophylaxis in the acute hospital care setting: report from the ENDORSE study in Egypt. Thromb J 2012; 10:20. [PMID: 22950681 PMCID: PMC3502290 DOI: 10.1186/1477-9560-10-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 08/13/2012] [Indexed: 12/24/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a leading cause of hospital-related deaths worldwide. However, the proportion of patients at risk of VTE who receive appropriate prophylaxis in Egypt is unknown. The ENDORSE study in Egypt is part of a global initiative to uncover the incidence of high-risk surgical and medical patients and determine what proportion of these patients receive appropriate VTE prophylaxis. Methods Ten Egyptian hospitals participated in this observational study, enrolling all surgical and medical patients that met the study criteria. This resulted in a cohort of 1,008 patients in acute care facilities who underwent a retrospective chart review. Each patient’s VTE risk status and the presence or absence of appropriate prophylactic care was assessed according to the American College of Chest Physicians (ACCP) guidelines 2004. Results Of the 1,008 patients enrolled, 395 (39.2%) were found to be at high-risk for VTE. Overall, 227 surgical patients were at high-risk, although only 80 (35.2%) received ACCP-recommended prophylaxis. Similarly, 55/268 (32.75%) of high-risk medical patients received appropriate VTE prophylaxis. Low molecular weight heparin was the most commonly used anticoagulant, while mechanical prophylactic use was quite low (1.5%) in high-risk patients. Conclusions In Egypt, more than one-third of all patients hospitalized for surgery or acute medical conditions are at high risk for developing VTE. However, only a small fraction of these patients receive appropriate VTE prophylaxis. Corrective measures are necessary for preventing VTE morbidity and mortality in these high risk patients.
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Affiliation(s)
- Hadi A Goubran
- Professor of Vascular Surgery, Ain Shams University, Cairo, Egypt.
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Essam AEN, Sharif G, Al-Hameed F. Venous thromboembolism-related mortality and morbidity in King Fahd General Hospital, Jeddah, Kingdom of Saudi Arabia. Ann Thorac Med 2012; 6:193-8. [PMID: 21977063 PMCID: PMC3183635 DOI: 10.4103/1817-1737.84772] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 04/25/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious and underestimated potentially fatal disease with an effective prophylactic antithrombotic therapy that is usually underused. OBJECTIVES The primary study objective is to determine the percentage of VTE patients who received prophylactic antithrombotic therapy according to ACCP guidelines. Secondary study objectives are determining prevalence of confirmed VTE mortality among all cause hospital mortalities, measuring adherence to anticoagulation treatment after discharge and number of VTE events among those patients. METHODS During the period from first of July 2008 till 30 of June 2009, we collected all hospital deaths, all patients with confirmed VTE diagnosis at King Fahd General Hospital, Jeddah, Kingdom of Saudi Arabia. Only patients with confirmed VTE diagnosis were included in the analysis. RESULTS Five hundred cases with clinical diagnosis of VTE were identified. Out of them 178 were confirmed to be VTE. 36.5% of them received prophylactic antithrombotic therapy. Case fatality rate was 20.8% representing 1.9% of hospital deaths. Case fatality rate was 31% and 3.1% for patients who did not receive thromboprophylaxis and patients who received it, respectively (P < 0.0001). 66.3% and 33.7% of confirmed VTE cases occurred in surgical and medical patients respectively. Only 44.1% of surgical patients and 21.7% of medical patients received prophylaxis (P < 0.01). Case fatality rate is 11% for surgical patients and 40% for medical patients (P < 0.001). Of 141 survived cases, 118 (83.7%) were adherent to anticoagulation therapy after discharge. CONCLUSIONS VTE prophylaxis guideline is not properly implemented and extremely underutilized. Mortality from VTE is significantly higher in patients who did not receive VTE prophylaxis. In the absence of regular post-mortem practice VTE related mortality rate would be difficult to estimate and likely will be underestimated. Health authorities should enforce VTE prophylaxis guideline within the healthcare system.
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Affiliation(s)
- Abo-El-Nazar Essam
- Department of Surgery Section Head liver Surgery-King Fahd General Hospital, Jeddah, Saudi Arabia
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Abstract
It is critically important to quickly recognize and treat acute pulmonary embolism (PE). Submassive and massive PEs are associated with right ventricular (RV) dysfunction and may culminate in RV failure, cardiac arrest, and death. A rapid and coordinated diagnostic and management approach can maximize success and save lives.
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Affiliation(s)
- Christian Castillo
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 2634 DUMC, Durham, NC 27710, USA
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Abstract
Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atherothrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing deep vein thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs.
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Affiliation(s)
- Samuel Z Goldhaber
- Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Cardiovascular Division, Boston, MA 02115, USA.
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Sharif-Kashani B, Shahabi P, Raeissi S, Behzadnia N, Shoaraka A, Shahrivari M, Saliminejad L, Pozhhan S, Hashemian MR, Masjedi MR, Bikdeli B. AssessMent of ProphylAxis for VenouS ThromboembolIsm in Hospitalized Patients. Clin Appl Thromb Hemost 2012; 18:462-8. [DOI: 10.1177/1076029611431955] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Venous thromboembolism (VTE) accounts for several cases of in-hospital mortality (over 100 000 deaths annually in the West). Despite the existence of effective prophylaxis guidelines for at-risk patients, the guidelines adherence is missing. Methods: We evaluated the thromboprophylaxis reception and appropriateness based on the eighth edition of the American College of Chest Physicians (ACCP) guidelines on VTE prophylaxis, among hospitalized patients of a World Health Organization (WHO)-collaborating teaching hospital in a 3-month period. Results: From the 904 evaluated cases, 481 entered the study. Appropriate decision on whether to prophylaxe or not, was made in 305 (63.40%), however, complete appropriateness (considering correct regimen type, dosing, and duration) was seen only in 229 patients (47.60%). The ACCP risk for VTE was the strongest predictor of thromboprophylaxis prescription (odds ratio [OR]: 2.62, 95% confidence interval [CI]: 1.35-5.05). Conclusions: Our thromboprophylaxis results were comparable to that of Western countries. Improved thromboprophylaxis appropriateness, which requires improving the physicians' thromboprophylaxis awareness and knowledge, could reduce the rate of in-hospital VTE and translate into better patient care.
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Affiliation(s)
- Babak Sharif-Kashani
- Tobacco Prevention and Control Research Center
- Lung Transplantation Research Center
| | | | | | | | | | | | | | | | | | - Mohammad-Reza Masjedi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih-Daneshvari Hospital, Shahid Beheshti University MC, Tehran, Iran
| | - Behnood Bikdeli
- Tobacco Prevention and Control Research Center
- Cardiovascular Research Center, Shahid Beheshti University MC, Tehran, Iran
- Center for Outcomes Research and Evaluation
- Section of Cardiovascular Medicine, Department of Internal medicine, Yale University School of Medicine, New Haven, CT, USA
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Mokhtari M, Salameh P, Kouchek M, Kashani BS, Taher A, Waked M. The AVAIL ME Extension: a multinational Middle Eastern survey of venous thromboembolism risk and prophylaxis. J Thromb Haemost 2011; 9:1340-9. [PMID: 21605327 DOI: 10.1111/j.1538-7836.2011.04336.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major worldwide problem. OBJECTIVES The primary objectives of this survey were to identify patients at risk for VTE, to define the rate of patients receiving appropriate VTE prophylaxis and to examine the frequency of the presence of guidelines and their application. PATIENTS AND METHODS Ten countries, 101 hospitals and a total of 4983 patients were included in this multinational cross-sectional survey. Standardized case report forms were filled out by trained individuals on one predefined day. Risks were categorized according to the Caprini Risk Assessment Model. Logistic regressions were carried out to assess factors that determined VTE prophylaxis. RESULTS Of 4983 patients, 3368 (68%) and 1615 (32%) were surgical and medical, respectively. Seven hundred and seventy-two (15.5%) were considered to be at low risk, 1001 (20%) at moderate risk, 1289 (26%) at high risk and 1921 (38.5%) at very high risk for VTE. Of 3575 (72%) patients who were eligible to receive VTE prophylaxis, 2747 (77%) received any drug prophylaxis. Among these patients 720/1056 (68%) and 2027/2519 (80%) were medical and surgical patients, respectively. The overall compliance with ACCP guidelines was 38%, being 24% for medical patients and 44% for surgical patients. CONCLUSIONS The results of this large multinational survey, although indicating overall improvement in VTE prophylaxis, identify a considerable number of patients who either did not receive any VTE prophylaxis or received it inappropriately. Although more medical patients were at risk for VTE, they were given prophylaxis less frequently than surgical patients. Concordance with VTE prophylaxis guidelines was higher in surgical patients, but overall application of these tools was unacceptably low.
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Affiliation(s)
- M Mokhtari
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Antithrombotic prophylaxis in the middle East. Mediterr J Hematol Infect Dis 2011; 3:e2011023. [PMID: 21713074 PMCID: PMC3113275 DOI: 10.4084/mjhid.2011.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 05/14/2011] [Indexed: 11/17/2022] Open
Abstract
Several factors have been proposed to explain the persistence of a high incidence of venous thromboembolism worldwide with its associated morbidity and mortality. Underutilization of anticoagulants and failure of adherence to thromboprophylaxis guidelines are emerging global health concerns. We herein review this alarming observation with special emphasis on the Middle East region. We also discuss strategies that could help control this increasingly reported problem.
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Amin AN, Lin J, Thompson S, Wiederkehr D. Real-World Rates of In-hospital and Postdischarge Deep-Vein Thrombosis and Pulmonary Embolism in At-Risk Medical Patients in the United States. Clin Appl Thromb Hemost 2011; 17:611-9. [DOI: 10.1177/1076029611405035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospitalized medical patients are at risk of deep-vein thrombosis (DVT) and pulmonary embolism (PE). We evaluated inpatient and postdischarge DVT/PE and thromboprophylaxis rates in US medical patients, using patient admissions from January 2005 to November 2007 in the Premier Perspective™-i3 Pharma Informatics database. Among 15 721 patients with cancer, congestive heart failure, severe lung disease, and infectious disease, 39.0% received inpatient thromboprophylaxis, with the highest rate in patients with cancer (51.9%). In all, 3.4% received outpatient pharmacological prophylaxis. Mean ± SD prophylaxis duration was 2.2 ± 5.7 days. Overall, 3.0% of inpatients had symptomatic DVT/PE, and an additional 1.1% of patients were rehospitalized for DVT/PE or treated in the outpatient setting. Patients with infectious disease had the highest rate of DVT/PE (4.6%). Inpatient DVT/PE and prophylaxis rates of the different medical conditions had a negative correlation ( R 2 = 0.72). This analysis demonstrates the burden of DVT/PE and highlights the underuse of thromboprophylaxis across the continuum of care.
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Affiliation(s)
- Alpesh N. Amin
- School of Medicine, University of California – Irvine, Irvine, CA, USA
| | - Jay Lin
- Bruce Wong & Associates, Inc, Radnor, Pennsylvania, PA, USA
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Abstract
Venous thromboembolism (VTE) is a major public health issue that is frequently underestimated. The primary objective of this multinational survey was to identify patients at risk for VTE, and to define the rate of patients receiving appropriate prophylaxis in the Middle Eastern region. Standardized case report forms were filled by trained individuals on one predefined day in selected hospitals. Data were then entered and analyzed by independent biostatisticians. Risk was categorized according to American College of Chest Physicians (ACCP) guidelines, 2004. Logistic regressions were carried out to assess factors that determined VTE prophylaxis. 845 (37%) medical and 1421 (63%) surgical patients were eligible for the study. Patients were at low (4.2%), moderate (51.7%), high (9%) and very high risk (35.2%) for VTE. Any VTE prevention was given in 17.9, 41.7, 60.6 and 66.9% of respective risk categories, while ACCP guidelines were applied in 86.3, 41.1, 48.3 and 24.5% of these categories. Surgical patient type, immobility on admission, and contraceptive use were the most important drivers of VTE prophylaxis in those who were eligible to it (OR ≥ 2). Surgical patient type, immobility during hospitalization, existence of a VTE protocol and chronic heart failure were the most important drivers for VTE prophylaxis application in patients who were not eligible for it (OR ≥ 3). A concordance κ value of 0.16 was found between eligibility for VTE prophylaxis on one hand and its application in practice (P < 0.001). Risk factors for VTE and eligibility for VTE prophylaxis are common, but VTE prophylaxis and guidelines application are low.
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Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH, Zotz RB, Bergmann JF, Tapson V, Froehlich JB, Monreal M, Merli GJ, Pavanello R, Turpie AGG, Nakamura M, Piovella F, Kakkar AK, Spencer FA. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest 2011; 140:706-714. [PMID: 21436241 DOI: 10.1378/chest.10-1944] [Citation(s) in RCA: 356] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Acutely ill hospitalized medical patients are at risk for VTE. We assessed the incidence of VTE in the observational International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) study and derived VTE risk assessment scores at admission and associative VTE scores during hospitalization. METHODS Data from 15,156 medical patients were analyzed to determine the cumulative incidence of clinically observed VTE over 3 months after admission. Multiple regression analysis identified factors associated with VTE risk. RESULTS Of the 184 patients who developed symptomatic VTE, 76 had pulmonary embolism, and 67 had lower-extremity DVT. Cumulative VTE incidence was 1.0%; 45% of events occurred after discharge. Factors independently associated with VTE were previous VTE, known thrombophilia, cancer, age > 60 years, lower-limb paralysis, immobilization ≥ 7 days, and admission to an ICU or coronary care unit (first four were available at admission). Points were assigned to each factor identified to give a total risk score for each patient. At admission, 67% of patients had a score ≥ 1. During hospitalization, 31% had a score ≥ 2; for a score of 2 or 3, observed VTE risk was 1.5% vs 5.7% for a score ≥ 4. Observed and predicted rates were similar for both models (C statistic, 0.65 and 0.69, respectively). During hospitalization, a score ≥ 2 was associated with higher overall and VTE-related mortality. CONCLUSIONS Weighted VTE risk scores derived from four clinical risk factors at hospital admission can predict VTE risk in acutely ill hospitalized medical patients. Scores derived from seven clinical factors during hospitalization may help us to further understand symptomatic VTE risk. These scores require external validation.
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Affiliation(s)
- Alex C Spyropoulos
- Hamilton Health Sciences General Hospital, McMaster University, Hamilton, ON, Canada.
| | - Frederick A Anderson
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA
| | - Gordon FitzGerald
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA
| | - Herve Decousus
- INSERM, CIE3, Saint-Etienne, University Saint-Etienne, CHU Saint-Etienne, Hôpital Nord, Service de Médecine Interne et Thérapeutique, Saint-Etienne, France
| | - Mario Pini
- Medicina Interna II, Fidenza Hospital, Parma, Italy
| | - Beng H Chong
- St. George Clinical School, University of New South Wales, Sydney, NSW, Australia
| | | | | | | | - James B Froehlich
- Vascular Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Manuel Monreal
- Servicio de Medicina Interna, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Geno J Merli
- Jefferson Vascular Diseases Center, Departments of Surgery and Medicine, Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Alexander G G Turpie
- Hamilton Health Sciences General Hospital, McMaster University, Hamilton, ON, Canada
| | - Mashio Nakamura
- Department of Cardiology, Mie University Graduate School of Medicine, Tsu Mie, Japan
| | - Franco Piovella
- U.O. Angiologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ajay K Kakkar
- Thrombosis Research Institute and University College London, London, England
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Abstract
PURPOSE OF REVIEW The aim is to provide a concise review of risk assessment models that stratify hospitalized acutely ill medical patients at risk of venous thromboembolism (VTE). RECENT FINDINGS Risk-assessment models (RAMs) for hospitalized medical patients at risk for VTE prior to 2005 attempted to identify at-risk patients using a point system or binary yes/no approach as to the existence of exposing (acute medical illness) or predisposing (genetic or clinical characteristic) risk factors for VTE. These RAMs were derived from data predominately from patient subgroups within randomized controlled trials and were cumbersome, not subject to rigorous validation, and were based on limited evidence of how these risk factors interacted in a quantitative manner. Recently, simplified RAMs have been proposed that have included this patient group. The RAMs are composed of various point systems and a threshold, which then would identify at-risk patient groups that would benefit from thromboprophylaxis. Although some of the point systems have been derived intuitively, they have been validated in large patient cohorts either prospectively or retrospectively and have shown good sensitivity. The presence of malignancy, prior VTE, hypercoagulability, advanced age and immobility all conferred increased risk of VTE during hospitalization or in the posthospital discharge period in the various models. SUMMARY Simple RAMs based on point systems to predict risk of VTE for the hospitalized medical patient have been validated that include either exposing or predisposing risk factors for VTE. It is hoped that these RAMs may identify acutely ill medical patients with additional characteristics that do not easily fit into group-specific thromboembolic risk assessment categories as currently proposed by international clinical guidelines.
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35
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Harrington DW. Choosing the right heparin prophylaxis strategy in medical patients at risk for developing VTE: an evidence-based approach. Hosp Pract (1995) 2010; 38:18-28. [PMID: 21068523 DOI: 10.3810/hp.2010.11.336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Many acutely ill medical patients are at significant risk for developing venous thromboembolism (VTE) during hospitalization. Venous thromboembolism risk arises from both the presenting clinical condition as well as predisposing risk factors, such as advanced age. Thromboprophylaxis is underprescribed in these patients. Thrombotic risk assessment could encourage the prescribing of thromboprophylaxis and, therefore, improve patient protection against VTE. Current guidelines from the American College of Chest Physicians and the International Union of Angiology (IUA) recommend thromboprophylaxis with low-dose unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH), or fondaparinux for acutely ill medical patients with VTE risk factors. However, the optimal dose regimen for UFH is unclear. The 2006 evidence-based guidelines from the IUA recommend a 3-times-daily dose regimen for UFH. However, UFH is usually administered twice daily despite a lack of evidence for the superiority of this regimen. Both heparin-induced thrombocytopenia and bleeding are associated with UFH, and to a lesser degree with alternative anticoagulants, such as the LMWHs. If utilized, an appropriate prophylaxis regimen in medical patients can reduce the risk of VTE and its burden.
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Affiliation(s)
- Darrell W Harrington
- David Geffen School of Medicine, UCLA, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start). J Thromb Thrombolysis 2010; 29:326-39. [PMID: 19548071 PMCID: PMC2837191 DOI: 10.1007/s11239-009-0361-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The 7th conference of the American College of Chest Physicians (ACCP7) provides recommendations on the type, dose, and duration of thromboprophylaxis in hospitalized patients at risk of venous thromboembolism (VTE), but the extent to which hospitals follow these criteria has not been well studied. Discharge and billing records for patients admitted to any of 16 acute-care hospitals from January 2005 to December 2006 were obtained. Patients 18 years or older who had an inpatient stay ≥2 days and no apparent contraindications for thromboprophylaxis were grouped into the categories of critical care, surgery and medically ill before being assessed for additional VTE risk factors based on the diagnostic criteria outlined in ACCP7. For patients at risk, the recommended type (mechanical or pharmacologic), dose, and duration of thromboprophylaxis was identified based on the guidelines and compared to the regimen actually received, if any. Among the 258,556 hospitalized patients, 68,278 (26.4%) were determined to be at risk of VTE without apparent contraindications for thromboprophylaxis. The proportions of patients who received the appropriate type, dose, and duration of thromboprophylaxis were 10.5, 9.8, and 17.9% for critical care, medical, and surgical patients, respectively. Of those at risk, 36.8% received no thromboprophylaxis and an additional 50.2% received thromboprophylaxis deemed inappropriate for one or more reasons. The implementation of ACCP7 guidelines for type, dosage, and duration of thromboprophylaxis is low in patients at risk of VTE. There is a need for physicians and health systems to improve awareness and implementation of recommended thromboprophylaxis.
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Dobesh P. The importance of appropriate prophylaxis for the prevention of venous thromboembolism in at-risk medical patients. Int J Clin Pract 2010; 64:1554-1562. [PMID: 20846203 DOI: 10.1111/j.1742-1241.2010.02447.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which encompasses both deep-vein thrombosis and pulmonary embolism, is a significant healthcare problem, leading to considerable morbidity, mortality and resource utilisation. AIMS This review discusses the adherence to VTE guideline recommendations and the available clinical evidence on the appropriate type, dose and duration of VTE prophylaxis. METHODS A literature survey was conducted using Pub Med and EMBASE to identify publications related to appropriate thromboprophylaxis in medically ill patients at risk of VTE. RESULTS Despite evidence from clinical trials and national guidelines, VTE prophylaxis in medically ill patients remains underutilised. The use of unfractionated heparin three-times-daily, low-molecular-weight heparin once-daily and fondaparinux once-daily has demonstrated effectiveness in clinical trials of medically ill patients. However, controversy exists about the use of unfractionated heparin twice-daily, and fondaparinux has not yet received US Food and Drug Administration approval for VTE prophylaxis in medically ill patients. CONCLUSION It is important for clinicians to have an understanding of the evidence-based literature when selecting an appropriate drug, at the appropriate dose, for the appropriate duration for VTE prophylaxis in medically ill patients. VTE prophylaxis in medically ill patients is cost-effective, and drugs that are expensive may still be cost-effective when considering improved efficacy and/or safety. Recently, the underutilisation of VTE prophylaxis has led to the involvement of government and other regulatory agencies in an attempt to increase appropriate VTE prophylaxis in US hospitals and improve the clinical and economic outcomes in medical patients at risk of VTE.
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Affiliation(s)
- P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, USA
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38
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Gaylis FD, Van SJ, Daneshvar MA, Gaylis GM, Gaylis JB, Sheela RB, Stern EJ, Hanson PB, Sur RL. Preprinted Standardized Orders Promote Venous Thromboembolism Prophylaxis Compared With Traditional Handwritten Orders: An Endorsement of Standardized Evidence-Based Practice. Am J Med Qual 2010; 25:449-56. [DOI: 10.1177/1062860610369824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Franklin D. Gaylis
- University of California San Diego, La Jolla, CA, Urology Specialty Associates, La Mesa, CA,
| | - Sothary J. Van
- Graduate School of Public Health, San Diego State University, San Diego, CA, College of Letters and Science, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Daneshvar
- College of Letters and Science, University of California Los Angeles, Los Angeles, CA
| | | | - Jaclyn B. Gaylis
- Emory College of Arts and Sciences, Emory University, Atlanta, GA
| | | | | | - Peter B. Hanson
- Grossmont Orthopaedic Medical Group, Sharp Grossmont Hospital, San Diego, CA
| | - Roger L. Sur
- University of California San Diego, La Jolla, CA, Urology Specialty Associates, La Mesa, CA, Uniformed Services University of the Health Sciences, Bethesda, MD
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Goldhaber SZ. Risk factors for venous thromboembolism. J Am Coll Cardiol 2010; 56:1-7. [PMID: 20620709 DOI: 10.1016/j.jacc.2010.01.057] [Citation(s) in RCA: 230] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 01/22/2010] [Accepted: 01/25/2010] [Indexed: 11/19/2022]
Abstract
Risk factors for venous thromboembolism (VTE) are often modifiable and overlap with risk factors for coronary artery disease. Encouraging our patients to adopt a heart-healthy lifestyle by abstaining from cigarettes, maintaining lean weight, limiting red meat intake, and controlling hypertension might lower the risk of pulmonary embolism and deep vein thrombosis (DVT), although a cause-effect relationship has not been firmly established. For hospitalized patients, guidelines have provided evidence-based strategies to identify patients at risk, such as elderly persons and those with cancer, congestive heart failure, or chronic obstructive pulmonary disease or undergoing major surgery. Most should receive pharmacological prophylaxis, which will minimize the risk of VTE. Because approximately 3 of every 4 pulmonary embolism and DVT events occur outside the hospital setting, patients should also be assessed for persistent high-risk of VTE at the time of hospital discharge.
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Affiliation(s)
- Samuel Z Goldhaber
- Harvard Medical School, Venous Thromboembolism Research Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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40
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Mahan CE, Pini M, Spyropoulos AC. Venous thromboembolism prophylaxis with unfractionated heparin in the hospitalized medical patient: the case for thrice daily over twice daily dosing. Intern Emerg Med 2010; 5:299-306. [PMID: 20177819 DOI: 10.1007/s11739-010-0359-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 01/12/2010] [Indexed: 10/19/2022]
Abstract
For venous thromboembolism (VTE) prevention in the hospitalized medical patient, no head-to-head trials have been performed of unfractionated heparin (UFH) 5,000 U subcutaneously thrice (i.e. q8 h or TID) daily versus twice daily (q12 h or BID). Several meta-analyses have been undertaken in attempts to determine whether one regimen may be more beneficial for safety and efficacy. Currently, not all international guidelines include a recommended frequency for UFH. Delineation of this frequency may be helpful to the practicing clinician. Primary studies (with a modified Jadad score of >or=6 to demonstrate a stronger study design) that compared low molecular weight heparin (LMWH) and UFH, and UFH and placebo were evaluated. Meta-analyses evaluating safety and efficacy of LMWH versus UFH, or TID UFH versus BID UFH were also evaluated. Although BID UFH shows some efficacy in one primary study, it is no more beneficial than no prophylaxis in another study. LMWH appears to be more efficacious than BID UFH, but comparable in safety and efficacy to TID UFH. Meta-analytic data demonstrates that BID UFH may have some reduction in deep vein thrombosis. Meta-analytic data also suggests that TID UFH is more efficacious than BID UFH at the cost of more major bleeding. The medical patient with risk factors for the development of VTE appears to be at moderate to high risk. International guidelines for VTE prevention should incorporate a frequency for UFH to guide use. TID UFH is superior in efficacy to BID UFH even when taking into consideration the increased rate of major bleeds. Newly published risk-assessment models may be beneficial in determining which patients would best benefit from BID UFH or TID UFH.
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Affiliation(s)
- Charles E Mahan
- Cardinal Health Pharmacy Solutions, Lovelace Medical Center, Lovelace Rehabilitation Hospital, Lovelace Health Systems, 601 Dr. Martin Luther King Jr. Ave. NE, Albuquerque, NM, 87102, USA.
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Galanter WL, Thambi M, Rosencranz H, Shah B, Falck S, Lin FJ, Nutescu E, Lambert B. Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital. Am J Health Syst Pharm 2010; 67:1265-73. [DOI: 10.2146/ajhp090575] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- William L. Galanter
- College of Medicine, Section of General Internal Medicine, and University of Illinois Hospital Information Services, and Clinical Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago (UIC)
| | - Mathew Thambi
- Department of Pharmacy Practice, College of Pharmacy, UIC
| | - Holly Rosencranz
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Bobby Shah
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Suzanne Falck
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Fang-Ju Lin
- Department of Pharmacy Administration, College of Pharmacy, UIC
| | - Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, UIC
| | - Bruce Lambert
- Department of Pharmacy Administration and Department of Pharmacy Practice, College of Pharmacy, UIC
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Amin A, Lin J, Ryan A. Lack of thromboprophylaxis across the care continuum in US medical patients. Hosp Pract (1995) 2010; 38:17-25. [PMID: 20499769 DOI: 10.3810/hp.2010.06.311] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Venous thromboembolism (VTE) prophylaxis is suboptimal, with many at-risk medical patients not receiving anticoagulants in hospital. Among those who receive anticoagulants in the hospital, thromboprophylaxis is frequently stopped at discharge despite persistent risk. Few studies have investigated prophylaxis use across the continuum of care. We analyzed anticoagulant use in medical patients in hospital and after discharge. Patient records (January 2005-December 2007) from medical patients with cancer, heart failure, severe lung disease, or infectious disease who were deemed at risk for VTE by the 2008 American College of Chest Physicians guidelines were included. Records were queried for inpatient and outpatient anticoagulant use by cross-matching data from the Premier Perspective discharge database with the i3/Ingenix LabRx outpatient and inpatient database. Of the 9675 medical patients identified, only 36.1% received inpatient anticoagulation (24.9% cancer patients, 30.1% infectious disease patients, 42.5% severe lung disease patients, and 56.3% heart failure patients). Of those who received in-hospital anticoagulants, most received enoxaparin (58.6%) followed by unfractionated heparin and other prophylactic agents. Only 1.8% of medical patients were prescribed anticoagulants within 30 days after discharge, ranging from 1.1% of patients with infectious disease to 4.8% of patients with heart failure. The majority of patients discharged who received outpatient anticoagulation filled prescriptions for warfarin, followed by enoxaparin plus warfarin. This real-world study demonstrates that only one-third of at-risk medical patients receive anticoagulants in hospital, with < 2% continuing to receive prophylaxis after discharge. Therefore, there is a need to improve the provision of thromboprophylaxis in the continuum of care for acutely ill medical patients.
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Affiliation(s)
- Alpesh Amin
- University of California, Irvine School of Medicine, Orange, CA 92868, USA.
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Merli G. Improving venous thromboembolism performance: a comprehensive guide for physicians and hospitalists. Hosp Pract (1995) 2010; 38:7-16. [PMID: 20499768 DOI: 10.3810/hp.2010.06.310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Venous thromboembolism (VTE) is a major potentially preventable cause of hospital deaths and is associated with a substantial clinical and economic burden in the United States. Despite the availability of effective thromboprophylactic agents and evidence-based management guidelines, VTE prophylaxis is commonly underused and inappropriately prescribed in real-world practice. Several US organizations have developed quality improvement initiatives to close the gap between guideline recommendations and clinical practice, and thus reduce VTE-associated morbidity and mortality. The Surgical Care Improvement Project and the National Quality Forum, in collaboration with The Joint Commission, have developed performance measures to allow assessment of the quality and appropriateness of VTE prevention practices. A number of potential barriers to optimal VTE performance exist, including underestimation of the risks posed by VTE, overestimation of the risk of bleeding complications, and a lack of familiarity with clinical guidelines. Hospitals are urged to develop an institution-wide policy to improve VTE prevention and employ several quality-improvement initiatives to overcome barriers and optimize prescribing practices. In particular, multiple integrated, active strategies are required to raise awareness of the need for appropriate VTE prophylaxis. Hospital-wide education, risk-assessment tools, electronic alerts, computerized decision-support systems, together with audit and feedback mechanisms, are valuable tools that can be used to promote the use of performance measures to drive improvement of VTE prophylaxis and clinical outcomes.
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Affiliation(s)
- Geno Merli
- Jefferson Center for Vascular Diseases, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Affiliation(s)
- Gregory Piazza
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z. Goldhaber
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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Outcomes for inpatients with normal findings on whole-leg ultrasonography: a prospective study. Am J Med 2010; 123:158-65. [PMID: 20103025 DOI: 10.1016/j.amjmed.2009.05.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 05/26/2009] [Accepted: 05/31/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasonography is used routinely for ruling out suspected deep vein thrombosis in hospitalized patients, although most evidence supporting this strategy is derived from the outpatient setting. This study aimed to estimate the rate of venous thromboembolism when anticoagulant therapy was withheld from inpatients with normal findings on whole-leg ultrasonography. METHODS As part of a prospective multicenter cohort study, 1926 medical and surgical inpatients with clinically suspected deep vein thrombosis during their stay were enrolled. Ultrasonography of all lower extremities was performed by board-certified vascular medicine physicians using a standardized examination protocol. Deep vein thrombosis was detected in 395 patients (20%). Anticoagulant therapy was withheld from patients with normal findings, and 523 of them were randomly selected for follow-up. The main outcome measure was 3-month incidence of symptomatic venous thromboembolism. RESULTS A total of 513 patients with normal findings on ultrasonography successfully completed 3 months of follow-up, 9 patients were lost to follow-up, and 1 patient received anticoagulant therapy during follow-up. Three patients (0.6%) experienced nonfatal symptomatic venous thromboembolic events confirmed by objective testing. The cause of death was judged to be possibly related to pulmonary embolism for 7 other patients (1.3%). Overall, the 3-month rate of venous thromboembolism was 1.9% (10/513; 95% confidence interval, 0.9-3.5). CONCLUSION Although withholding anticoagulant therapy after a single negative whole-leg ultrasonography seems to be safe, up to 3.5% of inpatients may nevertheless develop venous thromboembolism in the next 3 months. Further study is warranted to determine whether this strategy is equivalent to serial compression ultrasonography limited to proximal veins.
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Spyropoulos AC, Mahan C. Venous thromboembolism prophylaxis in the medical patient: controversies and perspectives. Am J Med 2009; 122:1077-84. [PMID: 19958882 DOI: 10.1016/j.amjmed.2009.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 04/04/2009] [Accepted: 04/08/2009] [Indexed: 10/20/2022]
Abstract
Despite the high morbidity and mortality associated with venous thromboembolism in hospitalized at-risk medical patients, the publication of large-scale studies showing that prophylaxis is effective in this patient group, and the presence of international guidelines, prophylaxis rates in medically ill patients remain suboptimal. Studies show that low-molecular-weight heparins, given once daily, are at least as effective as unfractionated heparin usually given thrice daily with equivalent or improved safety profiles, and that thrice-daily dosing of unfractionated heparin might be more effective than twice-daily dosing. However, the most recent American College of Chest Physicians guidelines do not distinguish between these regimens, and twice-daily unfractionated heparin is still commonly used in the United States. Furthermore, the optimal duration for out-of-hospital and extended prophylaxis for specific patient groups is not established. Finally, there are few data on the use of mechanical methods in this patient group and no established standard of care for prophylaxis of special patient populations, such as obese patients or those with renal insufficiency. Even though prophylaxis entails additional acquisition costs, it can reduce the incidence of venous thromboembolism, which can improve care and decrease overall costs.
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Piazza G, Fanikos J, Zayaruzny M, Goldhaber SZ. Venous thromboembolic events in hospitalised medical patients. Thromb Haemost 2009; 102:505-10. [PMID: 19718471 DOI: 10.1160/th09-03-0150] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of acutely ill hospitalised medical patients at risk for acute venous thromboembolism (VTE) has not been well defined. Therefore, we used the 2003 United States Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample database to estimate VTE events among hospitalised medical patients. We then modeled the potential reduction in VTE with universal utilisation of appropriate pharmacological thromboprophylaxis. We calculated that 8,077,919 acutely ill hospitalised medical patients were at risk for VTE. Heart failure, respiratory failure, pneumonia, and cancer were the most common medical diagnoses. We estimated that 196,134 VTE-related events occurred in 2003, afflicting two out of every 100 acutely ill hospitalised medical patients. These VTE-related events were comprised of 122,235 symptomatic deep venous thromboses, 32,654 symptomatic episodes of pulmonary embolism, and 41,245 deaths due to VTE. In our model, rates of pharmacological thromboprophylaxis prescription were low for various acute medical illnesses, ranging from 15.3% to 49.2%. However, with universal thromboprophylaxis, 114,174 VTE-related events would have been prevented. In conclusion, acutely ill medical patients represent a large population vulnerable to the development of VTE during hospitalisation. The number of VTE-related events would be halved with universal thromboprophylaxis. Further efforts focused on improving VTE prevention strategies in hospitalised medical patients are warranted.
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Affiliation(s)
- Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Abstract
Venous thromboembolism, a condition that includes deep vein thrombosis and pulmonary embolism, is a significant medical problem that affects more than 1 million patients each year. In addition to the immense impact of venous thromboembolism on morbidity and mortality, the economic burden of the disease is considerable, costing the health care system in the United States more than $1.5 billion/year. The cost of managing an initial episode of deep vein thrombosis is estimated at $7712-10,804, and for an initial pulmonary embolism event $9566-16,644. Management of acute venous thromboembolism in patients with cancer costs more than $20,000. Although much of the costs of venous thromboembolism are associated with managing the acute event, there are also significant costs associated with its long-term complications such as recurrent venous thromboembolism, postthrombotic syndrome, and pulmonary hypertension. Data from numerous robust clinical trials have demonstrated that with appropriate prophylaxis, many of these venous thromboembolism events can be prevented in both surgical and medical patients. Even though the strong evidence supporting venous thromboembolism prophylaxis spans several decades, a number of large American and global registries have documented very poor use of appropriate venous thromboprophylaxis. Because of increasing regulatory requirements, hospitals nationwide are developing necessary documentation of appropriate venous thromboembolism prophylaxis programs for both surgical and medical patients. Hospitals and clinicians must have a firm understanding of not only the clinical impact but also the economic impact of failing to use appropriate prophylaxis and of the cost-effectiveness of different venous thromboprophylaxis methods.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska 68198-6045, USA.
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Deitelzweig SB, Sasahara A, Michota F, McKean SC, Jacobson A. Guidelines-based use of thromboprophylaxis. J Hosp Med 2009; 4:S8-S15. [PMID: 19830847 DOI: 10.1002/jhm.596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Steven B Deitelzweig
- Department of Hospital Medicine, Ochsner Health System, New Orleans, LA 70121, USA.
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