Venous Thromboembolism Prophylaxis in Hospitalized Patients With Inflammatory Bowel Disease: Are We Falling Short?

Abstract

BACKGROUND: Venous Thromboembolism (VTE) in hospitalized Inflammatory Bowel Disease (IBD) patients increases length of stay by 48% and leads to a 59% increase in hospital charges1. Analyses show30% of gastroenterologists are unaware of ACG guidelines for VTE prophylaxis in hospitalized IBD patients; only 34% reported they would give prophylaxis to patients with an active flare2. We hypothesize that we under-prescribe prophylaxis in IBD patients due to misguided fear of poor outcomes such as bleeding. Our primary objective is to determine if Lankenau Medical Center adheres to guidelines set forth by gastroenterology societies as well as the American College of Chest Physicians in implementing VTE prophylaxis among hospitalized IBD patients. METHODS: We conducted a retrospective cohort study reviewing inpatient medical records for admissions to Lankenau Medical Center from January 1st, 2009 to December 31st, 2014 with an ICD diagnosis of IBD. Patients were evaluated regardless of admitting diagnosis. Exclusion criteria included age <18 and >90, and patients on long term systemic anticoagulation for any reason, including those with a history of VTE. We subsequently excluded charts from 2009 secondary to a lack of data within the electronic medical record. We collected data on IBD diagnosis (UC vs Crohns), and choice of VTE prophylaxis including enoxaparin, unfractionated heparin, sequential compression devices, Aspirin 81mg BID or none. Additional variables were collected for future analysis. We categorized VTE prophylaxis on admission as follows: a.) Appropriate VTE prophylaxis with heparin or Lovenox; b.) Inappropriate VTE prophylaxis, with sequential compression devices or aspirin; or c.) No VTE prophylaxis. RESULTS: 568 inpatient charts were evaluated. 182 of these met exclusion criteria; 386 were included. 99% (N=384) had a confirmed diagnosis of Crohn's disease while 1% (N=4) had Ulcerative Colitis. 49% of patients were placed on appropriate pharmacologic VTE prophylaxis (N= 189). Subcutaneous heparin was implemented in 12% while 37% were started on enoxaparin. The remaining 50% of our population was started on either inappropriate VTE prophylaxis or no prophylaxis at all. Of those started on inappropriate VTE prophylaxis on admission 20% received sequential compression devices while 2% received twice daily aspirin therapy. 27% of our study population was not started on any VTE prophylaxis on admission. CONCLUSION(S): Appropriate VTE prophylaxis in hospitalized IBD patients has been shown to decrease morbidity, length of stay, and cost. Nevertheless, even experts remain unaware of guideline recommendations for VTE prophylaxis in this population. We showed that our institution is currently falling short of recommendations. Further analysis will determine any significant variables influencing use of VTE prophylaxis in the 50% of our population with inadequate therapy; we hope to define the barriers to VTE prophylaxis initiation, in order to develop a comprehensive intervention to improve our compliance with these guidelines.