[Thromboprophylaxis: medical recommendations and hospital programs]

Adequacy of venous thromboembolism risk stratification and prophylaxis in a tertiary university hospital

Background

Venous thromboembolism is the third most common cardiovascular disease and the main cause of preventable death in hospitalized patients. Prophylaxis is still underused, despite well-established guidelines in the literature. Studies show a worldwide prophylaxis adequacy rate close to 50%.

Objectives

To assess the adequacy of risk stratification and prophylactic measures for venous thromboembolism in a tertiary university hospital.

Methods

A cross-sectional observational study was carried out, collecting data from medical records. Adult patients hospitalized by different specialties were enrolled and divided into surgical and clinical groups. The risk stratification of venous thromboembolism performed by the attending physicians was compared with stratification based on recent guidelines performed by the research physicians. Prophylaxis measures prescribed by the attending physicians were compared with guideline recommendations, thus obtaining the prophylaxis adequacy rate.

Results

400 patients were analyzed, 169 (42.3%) surgical and 231 (57.7%) clinical. The overall stratification adequacy rate was 50.8%. Adequacy rates were 39.1% and 59.3% in the surgical and clinical groups respectively (P < 0.0001). The overall prophylaxis adequacy rate was 71.5%, with 78.1% in the surgical group and 66.7% in the clinical group (P=0.0137).

Conclusions

Risk stratification adequacy is low, demonstrating a low awareness among prescribing physicians of the need for adequate stratification for prescription of prophylaxis. However, the prophylaxis prescription adequacy rates are higher than those in global data.

Evaluation of deep vein thrombosis prophylaxis in a general hospital

Background

Venous thromboembolism (VTE) is a cause for growing concern in hospitals, has great impact on morbidity and mortality in clinical and surgical patients, and is the leading cause of preventable hospital deaths. Although there are risk assessment models for hospital inpatients, prophylaxis is still underused or is administered incorrectly.

Objectives

To assess the risk profile for VTE in recently hospitalized clinical and surgical patients and evaluate the thromboprophylactic measures implemented in the first 24 hours of hospitalization.

Methods

Cross-sectional study conducted in a large general hospital in the state of São Paulo, Brazil, between March and July 2015. Padua and Caprini scores were used for risk stratification of clinical and surgical patients, respectively, while thromboprophylactic measures were analyzed for compliance with the recommendations contained in the 8th and 9th Consensus of the American College of Chest Physicians.

Results

A total of 592 patients (62% clinical and 38% surgical) were assessed. Risk stratification revealed a need for chemoprophylaxis in 42% of clinical patients and 81% of surgical patients (51% high risk and 30% moderate risk). However, 54% of high-risk clinical patients, 85% of high-risk surgical patients, and 4% of moderate-risk surgical patients, who were free from contraindications, were actually given the correct prophylaxis in the first 24 hours of hospitalization.

Conclusions

There is a need to improve patient safety in relation to VTE in the first hours of hospitalization, since there is underutilization of chemoprophylaxis, especially in high-risk clinical patients and moderate-risk surgical patients.

Derivation of a risk assessment model for hospital-acquired venous thrombosis: the NAVAL score

Venous thrombosis (VT) is a preventable cause of death in hospitalized patients. The main strategy to decrease VT incidence is timely thromboprophylaxis in at-risk patients. We sought to evaluate the reliability of risk assessment model (RAM) data, the incremental usefulness of additional variables and the modelling of an adjusted score (the NAVAL score). We used the RAM proposed by Caprini for initial assessment. A 5 % systematic sample of data was independently reviewed for reliability. We evaluated the incremental usefulness of six variables for VT during the score modelling by logistic regression. We then assessed the NAVAL score for calibration, reclassification and discrimination performances. We observed 11,091 patients with 37 (0.3 %) VT events. Using the Caprini RAM, high-risk and moderate-risk patients were respectively associated with a 17.4 (95 % confidence interval [CI] 6.1-49.9) and 4.2 (95 % CI 1.6-11.0) increased VT risk compared with low-risk patients. Four independent variables were selected for the NAVAL score: "Age", "Admission clinic", "History of previous VT event" and "History of thrombophilia". The area under the receiver-operating-characteristic curve for the NAVAL score was 0.72 (95 % CI 0.63-0.81). The Net Reclassification Index (NRI) for the NAVAL score compared with the Caprini RAM was -0.1 (95 % CI -0.3 to 0.1; p = 0.28). We conclude that the NAVAL score is a simplified tool for the stratification of VT risk in hospitalized patients. With only four variables, it demonstrated good performance and discrimination, but requires external validation before clinical application. We also confirm that the Caprini RAM can effectively stratify VT risk in hospitalized patients in our population.

Prevenção de tromboembolismo venoso em hospital com perfil oncológico: como melhorá-la?

Contexto

Complicações do tromboembolismo venoso são encontradas frequentemente em pacientes internados, tanto em condições clínicas quanto em pós-operatórios.

Objetivo

Verificar a quimioprofilaxia utilizada para tromboembolismo venoso em pacientes oncológicos internados, antes e após a realização de um programa de esclarecimento da sua importância.

Métodos

Estudo de corte transversal realizado em três momentos distintos: inicialmente antes do programa de conscientização da importância da profilaxia do tromboembolismo venoso, durante o período em que foi realizada e um ano após a etapa anterior. Para fins estatísticos, os pacientes foram divididos em alto risco e baixo risco, e estratificados quanto a erro na quimioprofilaxia em: precisavam, mas não fizeram profilaxia; não precisavam, mas fizeram profilaxia; fizeram profilaxia não padronizada; e não podiam, mas fizeram profilaxia.

Resultados

Foram avaliados 399 pacientes internados, sendo 56 pacientes antes do início do programa de conscientização, 255 durante o programa e 88 após um ano. Antes da realização da semana de conscientização, apenas 35,7% dos pacientes estavam recebendo a quimioprofilaxia adequada; após a semana de conscientização, houve um aumento do número de prescrições corretas, que passou para 63,9% (p < 0,001). Após um ano sem as aulas de conscientização, a manutenção da quimioprofilaxia não foi tão eficaz, com uma tendência ao aumento do número de profilaxias incorretas (p = 0,081).

Conclusão

A quimioprofilaxia é utilizada em uma porcentagem muito pequena nos pacientes internados, sendo necessários programas de esclarecimento de sua importância na prevenção do tromboembolismo venoso e a realização de monitoramento contínuo para auxiliar na sua prescrição.

Comparison of thromboprophylaxis patterns in arthroplasty in public and private hospitals

OBJECTIVE

To compare therapy for prophylaxis of venous thromboembolism and costs related to hospitalization of patients undergoing total knee and hip replacement within the context of the Brazilian health system.

METHODS

A retrospective study of patients undergoing arthroplasty in 2010 in a public hospital and two private hospitals in the state of São Paulo, conducted by means of medical record review. Costs were estimated based on the use of health care resources during hospitalization. A descriptive analysis was performed using frequency and mean (standard deviation) according to the type of care delivered (by public or private organization).

RESULTS

A total of 215 patients were evaluated, and 56.3% were submitted to knee surgery and 43.7%, to hip replacement. Approximately 88% and 98% of patients from public and private health services, respectively, received some form of venous thromboembolism prophylaxis, and enoxaparin was the drug most widely used in both systems. The total cost of prophylaxis was R$ 1,873.01 (R$ 26.38 per patient) in the public service and R$ 21,559.73 (R$ 163.33 per patient) in the private service. For the individuals who presented with thromboembolism, the average cost of hospitalization was R$ 6,210.80 and R$ 43,792.59 per patient in public and private health services, respectively.

CONCLUSION

Thromboembolism prophylaxis in patients undergoing arthroplasty is most commonly used in the private health services than public organizations, despite its high costs in both services. The cost per patient with thrombosis during hospitalization was higher than the total cost of prophylaxis, suggesting that prevention is associated to better cost-benefit ratio.