Inpatient Venous Thromboembolism Research Articles

Statins in the prevention of venous thromboembolism: A meta-analysis of observational studies

Introduction Studies have established a relationship between inflammation and venous thromboembolism (VTE). Though statins modulate inflammation, it is uncertain if they prevent VTE in heterogeneous populations. A recent randomized trial demonstrated that statins prevent VTE in healthy older adults, yet this has not been well established in other groups, including younger individuals and individuals with comorbidities. The objective of this meta-analysis was to estimate the effect of statins on VTE in a heterogeneous group of adults. Methods We systematically reviewed the effect of statins in preventing VTE in adult inpatients and outpatients. We systematically searched MEDLINE (1966-Jan 2010), EMBASE (1980-Jan 2010), Google Scholar, Cochrane Library, PapersFirst, ProceedingsFirst, and ISI Web of Science, manually reviewed references, and contacted experts. Observational studies that compared any dose of statin to no statin or placebo, examined inpatients or outpatients, and assessed VTE, pulmonary embolism, and/or deep vein thrombosis were included. Study selection, data abstraction and study quality evaluation (using the Newcastle-Ottawa Scale) were independently conducted in duplicate. Results Four cohort studies and four case-control studies met criteria. Comparing statins to control, the odds ratio for VTE was 0.67 (95% confidence interval 0.53, 0.84), and for deep vein thrombosis was 0.53 (95% confidence interval 0.22, 1.29). The association was attenuated in lower-quality studies and studies enrolling older individuals. Conclusions Further well-designed trials are needed to evaluate the risks and benefits of statins in preventing VTE in heterogenous populations of adults, identify high-risk subgroups, and analyze cost-effectiveness of statin use for this indication.

Economic impact of an electronic alert system to prevent venous thromboembolism in hospitalised patients

The prevention of venous thromboembolism (VTE) is a priority for improved safety in hospitalised patients. Worldwide, there is growing concern over the undersuse of appropriate thromboprophylaxis. Computerised decision support improves the implementation of thromboprophylaxis and reduces inpatient VTE. However, an economic assessment of this approach has not yet been performed. To evaluate the economic impact of an electronic alert (e-alert) system to prevent VTE in hospitalised patients over a 4year period. All hospitalised patients at a single institution during the first semesters of 2005-2009 (n=32280) were included. All cases of VTE developed during hospitalisation were followed and direct costs of diagnosis and management collected. E-alerts achieved a sustained reduction of the incidence of in-hospital VTE, OR 0.50 (95% CI, 0.29-0.84), the impact being especially significant in medical patients, OR 0.44 (95% CI, 0.22-0.86). No increase in prophylaxis-related bleeding was observed. In our setting, the mean direct cost (during hospitalisation and after discharge) of an in-hospital VTE episode is €7058. Direct costs per single hospitalised patient were reduced after e-alerts from €21.6 to €11.8, while the increased use of thromboprophylaxis and the development of e-alerts meant €3 and €0.35 per patient, respectively. Thus, the implementation of e-alerts led to a net cost saving of €6.5 per hospitalised patient. Should all hospitalised patients in Spain be considered, total yearly savings would approach €30million. E-alerts are useful and cost-effective tools for thromboprophylaxis strategy in hospitalised patients. Fewer thromboembolic complications and lower costs are achieved by its implementation.

Evaluation of venous thromboembolism risk following hospitalization

A better understanding of the relationship between outpatient venous thromboembolism (VTE) and prior hospitalization is needed including data regarding the utilization of inpatient pharmacologic VTE prophylaxis and its effect on outpatient venous thromboembolic risk. The primary objective was to assess the association between development of outpatient VTE and inpatient hospitalization within the previous 90 days. Additional outcome measures included describing patients who received pharmacologic anticoagulation during hospitalization and identification of factors independently associated with VTE. Case patients in this matched case-control study were diagnosed with an outpatient deep vein thrombosis or pulmonary embolus between January 2005 and December 2007 and were matched on age with up to five to patients who were seen for an outpatient health maintenance visit but had no VTE during the same time frame as their matched case. Information collected from electronic administrative databases and patient medical records included health services utilization, medication use, medical diagnoses, and patient demographic information. Of 2190 cases, 560 patients (25.6%) compared to 151 (1.4%) of 10,942 control patients were hospitalized in the previous 90 days (P < 0.001). Among hospitalized patients, 53.5% of cases and 47.0% of controls received an anticoagulant during hospitalization (P = 0.186). Factors associated with a VTE diagnosis included hospitalization for a surgical, medical, or orthopedic indication in the previous 90 days, younger age, longer hospitalization, cancer and an elevated Chronic Disease Score. A strong association exists between outpatient VTE diagnosis and hospitalization and gaps in pharmacologic prophylaxis utilization during hospitalization are evident.

Incidence de la maladie thromboembolique veineuse chez des hommes admis dans un service de pneumologie pour affection respiratoire aiguë

Venous thromboembolism (VTE) is a major source of morbidity and mortality all over the world. It is one of the complications arising in a hospital environment. The main aim of this study is to estimate the incidence of VTE in respiratory inpatients. The authors carried out a prospective study on acute respiratory disease inpatients. A medical analytical index card was used. An echo-venous Doppler of lower limbs was practiced on D1 and D10 of hospitalization. The Wells scored was used to estimate the clinical probability of the occurrence of VTE. Seven of 100 patients studied developed VTE (95% CI: 2-12%), four of which presented a pulmonary embolism. The patients with VTE are 60-years-old±11.67. The incidence of VTE includes 20% (95% CI: 12.2-27.8%) of the patients hospitalized for bronchial cancer, 7.14% (95% CI: 2.1-12.18) of the patients presenting pulmonary tuberculosis and 4.54% (95% CI: 0.46-8.62%) of the patients hospitalized for exacerbation of chronic obstructive pulmonary disease (COPD). The duration of hospitalization was prolonged for the treatment of VTE (21±4.41 days for these patients compared with 12±5 days in the absence of VTE (P<0.001)). The analysis of the various risk factors shows that a Performance Status>2 (P=0.005) and lung cancer (P=0.028) are the factors most incriminated in the occurrence of VTE. It is associated with a mortality of 2%. VTE is a reality which is necessary to prevent in respiratory inpatients in situations at risk, especially in patients with lung cancer and with a PS>2.

Rivaroxaban for thromboembolism prophylaxis after orthopaedic surgery

Rivaroxaban for thromboembolism prophylaxis after orthopaedic surgery

Prevention and Clinical Outcomes in Older Inpatients with Suspected Venous Thromboembolism

Venous thromboembolism (VTE) is one of the most common preventable disorders among hospital inpatients. Advancing age is a major risk factor for VTE. The purpose of this study was to describe and compare prevention practices and clinical outcomes in older (age 65 and older) versus younger (ages 18 to 64) hospitalized patients at risk for or diagnosed with VTE. Medical charts of 210 older and 450 younger inpatients undergoing diagnostic tests to rule out VTE were reviewed at an academic medical center. Acute VTE was diagnosed in 17.1% of older and 22.7% of younger inpatients. Pharmacological prophylaxis was used in 70% of eligible older and 57% of eligible younger inpatients. Nearly one quarter of eligible older inpatients did not receive any VTE prevention measures. The 3-month mortality was higher in older inpatients (13.9%) compared with younger inpatients (9.8%) with VTE, despite the lower rate of VTE in older inpatients. Prevention measures for VTE were underused in both older and younger inpatients.

Fattori di rischio per tromboembolismo venoso e profilassi nei pazienti ricoverati in Medicina Interna: analisi dallo studio FADOI “GEMINI”

Though venous thromboembolism (VTE) frequently occurs in non-surgical setting, epidemiology and risk factors for VTE in unselected medical inpatients have not been extensively studied, and uncertainties remain about the prophylactic strategy in these patients. In a prospective, observational, multicenter study we aimed to contemporarily assess the epidemiology of symptomatic VTE in consecutive patients hospitalized in Internal Medicine, to evaluate the impact of potential risk factors, and the attitude of internists towards thromboprophylaxis. A total of 4,846 patients were included, during the period March-September 2006. Symptomatic VTE was registered in 177 (3.65%) patients; of these, 26 cases (0.55%) occurred with onset of symptoms ≥ 48 hours after admission (“hospital-acquired” events, primary study end-point). Previous VTE and bed resting were significantly associated with venous thromboembolism, while a trend for increased risk was documented in cancer patients. During hospital stay antithrombotic prophylaxis was globally administered in 41.6% of patients, and in 58.4% of those for which prophylaxis was recommended according to 2004 guidelines by the American College of Chest Physicians. The choice of administering tromboprophylaxis appeared qualitatively adherent to indications from randomized trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a quite common finding in patients admitted to Internal Medicine departments, and recommended tromboprophylaxis is still underused, in particular in some patients groups. Further efforts are needed to better define the risk profile and to optimize prophylaxis in the heterogeneous setting of medical patients.

Inpatient thromboprophylaxis use in U.S. hospitals: Adherence to the seventh American College of Chest Physician's recommendations for at‐risk medical and surgical patients

The clinical venous thromboembolism (VTE) burden remains high in the United States, despite guidelines recommending that safe and effective VTE prophylaxis be available. This study assesses the real-world rate of appropriate inpatient VTE prophylaxis in hospitalized U.S. medical and surgical patients at risk of VTE, in accordance with the seventh American College of Chest Physicians, (ACCP) guidelines. Medical and surgical discharges from Premier's Perspective database between January 1, 2005 and December 31, 2006 were considered. Discharges aged > or = 40 years, with a length of stay > or = 6 days, at risk of VTE due to the presence of > or = 1 VTE risk factors identified by the seventh ACCP guidelines, and without contraindications for anticoagulation, were included in the analysis. Appropriate prophylaxis was determined by comparing the daily use, dosage, and duration of anticoagulants and compression devices with the seventh ACCP recommendations for each medical condition or surgical procedure. A total of 390,024 discharges met the inclusion criteria, of which 201,224 (51.6%) were medical discharges and 188,800 (48.4%) were surgical discharges. Overall, 65.9% of medical discharges and 77.7% of surgical discharges received at least 1 order for VTE prophylaxis during hospitalization. However, only 12.7% of medical discharges and 16.4% of surgical discharges received appropriate prophylaxis when the recommended prophylaxis type, dose, and duration from the seventh ACCP guidelines were taken into account. Few medical and surgical patients at high risk of VTE receive appropriate inpatient prophylaxis in accordance with guideline recommendations. It is important for individual hospitals to improve VTE prophylaxis practices to meet national performance initiatives.

In-hospital symptomatic venous thromboembolism and antithrombotic prophylaxis in Internal Medicine

Hospitalised medical patients are at increased risk of venous thromboembolism (VTE), but the incidence of hospitalisation-related VTE in unselected medical inpatients has not been extensively studied, and uncertainties remain about the optimal use of thromboprophylaxis in this setting. Aims of our prospective, observational study were to assess the prevalence of VTE and the incidence of symptomatic, hospitalisation-related events in a cohort of consecutive patients admitted to 27 Internal Medicine Departments, and to evaluate clinical factors associated with the use of thromboprophylaxis. Between March and September 2006, a total of 4,846 patients were included in the study. Symptomatic VTE with onset of symptoms later than 48 hours after admission ("hospital-acquired" events, primary study end-point) occurred in 26 patients (0.55%), while the overall prevalence of VTE (including diagnosis prior to or at admission) was 3.65%. During hospital stay antithrombotic prophylaxis was administered in 41.6% of patients, and in 58.7% of those for whom prophylaxis was recommended according to the 2004 Guidelines of the American College of Chest Physicians. The choice of administering thromboprophylaxis or not appeared qualitatively adherent to indications from randomised clinical trials and international guidelines, and bed rest was the strongest determinant of the use of prophylaxis. Data from our real-world study confirm that VTE is a relevant complication in patients admitted to Internal Medicine Departments, and recommended tromboprophylaxis is still under-used, in particular in some patients groups. Further efforts are needed to better define risk profile and to optimise prophylaxis in the heterogeneous setting of medical inpatients.

D-Dimers, Thrombin—Antithrombin Complexes, and Risk Factors for Thromboembolism in Hospitalized Patient

There is lack of data about the correlation between hemostatic markers and the clinical and biological risk factors (RFs) for venous thromboembolism (VTE) in medical inpatients without suspicion of acute VTE. To evaluate the coagulation activation status in patients with current known RFs for VTE, the authors measured 2 markers of hypercoagulability, thrombin antithrombin (TAT) complexes and D-dimers, at day 1 in 165 patients hospitalized in internal medicine wards without suspected acute VTE. All known RFs for VTE were systematically assessed at admission and classified in a chronological way as permanent or transient. Surprisingly, TAT values followed a multimodal distribution. D-dimers showed a normal distribution after a logarithmic transformation (P = .34, Shapiro-Wilk test). Interestingly, a significant progression in D-dimer levels was found according to the chronological classification of RFs. D-dimer variations on multivariate analysis (not applicable for TAT because of the multimodal distribution) correlated independently with a recent inability to walk and an increase in C reactive protein level more than 10 mg/L. (a) this study is the first to describe the variations of hypercoagulability markers according to a systematic screening of RFs for VTE in inpatients without suspicion of acute VTE, (b) TAT appeared as a less relevant marker of hypercoagulability than D-dimers in internal medicine inpatients, (d) the chronological classification of RFs identified clearly groups at risk for the prethrombotic state, and (d) an increased hypercoagulability state was demonstrated in patients with an association between a recent immobility and increased inflammatory markers.

Misconceptions About Venous Thromboembolism

Some clinicians may believe that inpatient venous thromboembolism (VTE) is far more common than outpatient VTE and that outpatient VTE generally occurs

Frequency of thromboprophylaxis and incidence of in-hospital venous thromboembolism in a cohort of emergency department patients

Prior work suggests that in-hospital pulmonary and venous thromboembolism (VTE) could be decreased if the rate of prophylaxis for VTE in high-risk patients were increased at the time of admission. Our objective was to quantify the rate of thromboprophylaxis and incidence of in-hospital VTE, based upon risk of VTE, in a cohort of patients admitted through the emergency department (ED). We performed a prospective cohort study at an urban ED with >100,000 visits. All medical patients >17 years admitted from the ED were prospectively identified on a random sample of days for one year. Using a structured data form we collected each patient's risk factors for VTE, and prophylaxis measures. We computed a validated risk score of each patient, with a score >or=4 high-risk (HR) and a score <4 low risk (LR). The main outcome was VTE during the hospitalization, diagnosed after admission from ED. Of 4732 patients, VTE was diagnosed during hospitalization in 44 (0.9%). 437 (9%) patients were HR for VTE and HR patients had significantly higher frequency of VTE vs. LR patients, 1.8 vs. 0.8% (95% CI for difference of 1% = 0.1-3%). Only 36% of HR patients received thromboprophylaxis. There were no significant differences in the frequency of observed inpatient VTE events between patients who were prescribed prophylaxis compared with those who were not prescribed prophylaxis in either risk group. These data suggest only a modest opportunity for ED-based policy for thromboprophylaxis in admitted medical patients.

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: summary of NICE guidance

Deep vein thrombosis occurs in over 20% of patients having major surgery and over 40% of patients having major orthopaedic surgery. The postoperative risk of pulmonary embolism can be as...

Venous Thromboembolic Disease

Venous thromboembolic disease is a common and life-threatening condition in cancer patients. Results from a recent retrospective study of 66,106 hospitalized adult neutropenic cancer patients showed that 2.74% to 12.10% of these patients, depending on the type of malignancy, experienced a venous thromboembolism (VTE) during first hospitalization. These guidelines specifically outline strategies to prevent and treat VTE in adult inpatients with either a diagnosis of cancer or for whom cancer is clinically suspected. These guidelines evaluate the therapeutic advantages of implementing pharmacologic anticoagulation measures based on both the perceived risk for bleeding (i.e., contraindications to anticoagulation) and the status of the cancer. For the most recent version of the guidelines, please visit NCCN.org

Have Palliative Care Teams' Attitudes Toward Venous Thromboembolism Changed? A Survey of Thromboprophylaxis Practice Across British Specialist Palliative Care Units in the Years 2000 and 2005

Palliative care patients are highly prothrombotic, yet there are no national guidelines for the prevention of venous thromboembolism (VTE). A survey was undertaken to explore thromboprophylaxis practice within British palliative care inpatient units and whether it changed over 5 years in keeping with emerging evidence. A descriptive semistructured telephone survey was conducted in April, 2000 and March, 2005 to explore current thromboprophylaxis practice. Seventy-four percent of units participated in 2000 and 91% participated in 2005. Units surveyed in 2000 revealed that 2% had thromboprophylaxis guidelines and up to 75% would stop ongoing low molecular weight heparin (LMWH) in a highly prothrombotic, good prognosis inpatient. The survey in 2005 indicated that thromboprophylaxis guidelines were being developed in 19% of units and only 18% of units surveyed would stop LMWH in a patient already receiving thromboprophylaxis ( P < 0.001). There appears to be a growing awareness of the problem of VTE in British palliative care inpatients, as evidenced by changes in attitudes and practice. Reasons for this are discussed.

Cost utility of substituting enoxaparin for unfractionated heparin for prophylaxis of venous thrombosis in the hospitalized medical patient

Both heparin and enoxaparin are effective for the prevention of venous thromboembolism (VTE) in medical patients. On the basis of price, heparin appears preferable because it is less expensive. However, choosing enoxaparin may have greater cost utility when the outcomes of heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are considered. To determine the cost utility of substituting enoxaparin for heparin from payer and institutional perspectives. A decision analysis model was used. Cost data were based on Medicare reimbursement and the medication and laboratory costs for a multi-institutional healthcare system. Quality-adjusted life years (QALYs) saved by preventing HIT/HITT through the use of enoxaparin were based on published data. Costs are expressed on a per-day basis, and the incremental cost of enoxaparin over that of heparin was used in the calculation of cost/QALY. A sensitivity analysis also was performed. Inpatient medicine. All medical patients for whom VTE prophylaxis was appropriate. Substitution of enoxaparin for heparin. Cost/QALY. From a payer perspective, using enoxaparin resulted in a decrease in cost of 28.61 dollars over that of heparin and saved 0.00629 QALYs in the base case, resulting in a savings of 4550.17 dollars/QALY. The sensitivity analysis showed this finding of decreased cost and increased effectiveness to be consistent. From an institutional perspective, the use of heparin generally appeared less costly but was dependent on medication price, length of stay required, and bed utilization. From a payer and, by extrapolation, a societal perspective, cost-utility analysis supports the use of enoxaparin in place of heparin for the prevention of VTE in medical inpatients. From an institutional perspective, the decision is more complicated, but in most cases, the use of enoxaparin also is supported.

Efficacy of Venous Thromboembolism Prophylaxis in Morbidly Obese Patients Undergoing Gastric Bypass Surgery

Patients undergoing gastric bypass are at risk of developing venous thromboembolism (VTE) due to multiple risk factors including obesity and abdominal surgery. The purpose of this study is to evaluate the effectiveness of inpatient VTE prophylaxis in morbidly obese patients undergoing gastric bypass and the incidence of symptomatic VTE following discharge. A retrospective chart review of patients undergoing gastric bypass from August 2000 to August 2001 was performed. Inpatient charts from medical records and physician outpatient office charts were reviewed. Evaluation consisted of: VTE prophylaxis utilized, acquired risk factors for VTE, BMI, development of deep venous thrombosis (DVT) or pulmonary embolism (PE) during hospitalization, outpatient office visits following discharge, and VTE after discharge. 107 patient charts were reviewed. There were no incidences of VTE documented during hospitalization, and only one patient developed a symptomatic DVT after discharge. During hospitalization, all patients received DVT prophylaxis consisting of medical management, external compression devices, and ambulation orders. At the time of surgery, patients had a mean age of 40 years (23-69 years) and a BMI of 51.3 kg/m2 (37-82). Surgery lasted a mean of 108.9 minutes (65-305), patients were hospitalized for a mean of 4.3 days (3-7), and had a mean of 3.4 risk factors (2-7 risk factors) for the development of VTE. After hospital discharge, 101 patients were followed for the development of VTE. Combination of medical management, early ambulation, and external compression devices adequately prevented the development of VTE in patients after gastric bypass.