We thank the authors [1Gianese F. Prandoni P. More on: venous thromboembolism and mortality after hip fracture: the ESCORTE study.J Thromb Haemost. 2006; 4: 1642-5Abstract Full Text Full Text PDF PubMed Google Scholar] for taking the time to review and criticize our publication [2Rosencher N. Vielpeau C. Emmerich J. Fagnani F. Samama C.M. Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study.J Thromb Haemost. 2005; 3: 2006-14Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar] of the ESCORTE study. However, we strongly disagree with some of their arguments and would like to take the opportunity to comment on several points they have made. Firstly, we would like to emphasize that the ESCORTE study was designed to evaluate common practices and is the largest prospective cohort study in this setting. As we stated in our paper, we still believe our data provide a valid picture of the routine management of hip fracture surgery patients. Although we agree with the authors that ‘manifestations of postoperative venous thromboembolic events (VTE) are elusive and, …easily confounded by swelling and tenderness of the operated limb’, we would suggest that symptoms of these complications do not generally appear in the early postoperative period [3Eriksson B.I. Lassen M.R. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo‐controlled, double‐blind study.Arch Intern Med. 2003; 163: 1337-42Crossref PubMed Scopus (0) Google Scholar], and thus would not have influenced our findings, as VTE was assessed at 3 months. Furthermore, the authors suggest that postoperative VTE is difficult to verify if venography is not performed; however, this invasive method is not commonly used in clinical practice and may be responsible for variability of interpretation according to the different observers [4Lensing A.W. Buller H.R. Prandoni P. Batchelor D. Molenaar A.H. Cogo A. Vigo M. Huisman P.M. Ten Cate J.W. Contrast phlebography, the gold standard for the diagnosis of deep venous thrombosis: improvement in observer agreement.Thromb Haemost. 1992; 67: 8-12Crossref PubMed Google Scholar]. Even though compression ultrasound (CUD) has less sensitivity for identifying asymptomatic deep vein thrombosis (DVT) [5Kassai B. Boissel J.P. Cucherat M. Sonie S. Shah N.R. Leizorovicz A. A systematic review of the accuracy of ultrasound in diagnosis of deep venous thrombosis in asymptomatic patients.Thromb Haemost. 2004; 91: 655-66Crossref PubMed Google Scholar, 6Leizorovicz A. Cohen A.T. Turpie A.G. Olsson C.G. Vaitkus P.T. Goldhaber S.Z. PREVENT Medical Thromboprophylaxis Study GroupRandomized, placebo‐controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients.Circulation. 2004; 110: 874-9Crossref PubMed Scopus (842) Google Scholar, 7Prandoni P. Controversial issues in the diagnosis of venous thromboembolism.Pathophysiol Haemost Thromb. 2003/2004; 33: 311-3Crossref PubMed Scopus (2) Google Scholar], this technique has been validated as the first‐line diagnostic test in suspected symptomatic DVT [8Cogo A. Lensing A.W. Koopman M.M. Piovella F. Siragusa S. Wells P. Villalta S. Buller H. Turpie A.G. Prandoni P. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis.BMJ. 1998; 316: 17-20Crossref PubMed Google Scholar], for either postoperative or ambulatory patients [8Cogo A. Lensing A.W. Koopman M.M. Piovella F. Siragusa S. Wells P. Villalta S. Buller H. Turpie A.G. Prandoni P. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis.BMJ. 1998; 316: 17-20Crossref PubMed Google Scholar, 9Prandoni P. Lensing A. Bernardi E. Villalta S. Bagatella P. Girolami A. DERECUS Investigators GroupThe diagnostic value of compression ultrasonography in patients with suspected recurrent deep vein thrombosis.Thromb Haemost. 2002; 88: 402-6Crossref PubMed Google Scholar]. Following recommendations made by the European Medicines Agency (EMEA) [10Committee for Proprietary Medicinal ProductsPoints to Consider on Clinical Investigation of Medicinal Products for Prophylaxis of Intra‐ and Postoperative Venous Thromboembolic Risk. The European Agency for the Evaluation of Medicinal Products. CPMP/EWP/707/98, 2000Google Scholar], a recent prospective study used symptomatic VTE and proximal venous thrombosis, detected by CUD, as a primary composite endpoint [6Leizorovicz A. Cohen A.T. Turpie A.G. Olsson C.G. Vaitkus P.T. Goldhaber S.Z. PREVENT Medical Thromboprophylaxis Study GroupRandomized, placebo‐controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients.Circulation. 2004; 110: 874-9Crossref PubMed Scopus (842) Google Scholar]. For ESCORTE, we purposely chose to focus on clinical or symptomatic VTE reported in practice by local investigators who followed a large patient population, and we would argue that the large number of investigators (from 529 centers) limits judgement errors in detection. Another advantage of the large population studied in ESCORTE is the identification of precise point estimates. In fact, during this unique period of assessment in 6860 patients, our results provided smaller confidence intervals than any of the previously conducted studies, and are more precise than the pooled analysis of 4076 patients from various trials [11Dahl O.E. Caprini J.A. Colwell Jr, C.W. Frostick S.P. Haas S. Hull R.D. Laporte S. Stein P.D. Fatal vascular outcomes following major orthopaedic surgery.Thromb Haemost. 2005; 93: 860-6Crossref PubMed Scopus (71) Google Scholar] that was cited by the authors [1Gianese F. Prandoni P. More on: venous thromboembolism and mortality after hip fracture: the ESCORTE study.J Thromb Haemost. 2006; 4: 1642-5Abstract Full Text Full Text PDF PubMed Google Scholar]. More importantly, we believe that using symptomatic VTE as a primary endpoint in ESCORTE is more relevant than using asymptomatic VTE; in real‐life practice, systematic screening is not performed and only symptomatic VTE would translate to a therapeutic consequence (i.e. curative treatment). The quality of the follow‐up data in ESCORTE also limits the chance that the true incidence of the disease was underestimated. At the end of the in‐hospital period (roughly 2 weeks), more than 90% of the patients left the surgical unit for placement in rehabilitation centers. We strongly feel that physicians in these centers would have been able to diagnose DVTs. The authors [1Gianese F. Prandoni P. More on: venous thromboembolism and mortality after hip fracture: the ESCORTE study.J Thromb Haemost. 2006; 4: 1642-5Abstract Full Text Full Text PDF PubMed Google Scholar] suggest that ESCORTE presented an ‘unexpected picture’ based on their reference to a previously published pooled analysis that indicated a higher rate of autopsy‐proven fatal pulmonary embolism (PE), and to three recently conducted prospective studies [12Eikelboom J. Quinlan D. Douketis J. Extended‐duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta‐analysis of the randomised trials.Lancet. 2001; 358: 9-15Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 13Pulmonary Embolism Prevention (PEP) Trial Collaborative GroupPrevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.Lancet. 2000; 355: 1295-302Abstract Full Text Full Text PDF PubMed Google Scholar, 14Freeman C. Todd C. Camilleri‐Ferrante C. Laxton C. Murrell P. Palmer C.R. Parker M. Payne B. Rushton N. Quality improvement in patients with hip fracture: experience from a multisite audit.Qual Saf Health Care. 2002; 11: 239-45Crossref PubMed Google Scholar]. We agree with the authors that the absence of autopsy could lead to underestimation of the true rate of fatal PE; however, autopsies are not performed in daily clinical practice. Also, in the study of Dahl et al. [11Dahl O.E. Caprini J.A. Colwell Jr, C.W. Frostick S.P. Haas S. Hull R.D. Laporte S. Stein P.D. Fatal vascular outcomes following major orthopaedic surgery.Thromb Haemost. 2005; 93: 860-6Crossref PubMed Scopus (71) Google Scholar], the higher rate of fatal PE is based on data from pooled analyses of studies conducted between 1981 and 1995, when extended prophylaxis was not used. Because the incidence of PE decreased by about 45% over this 15‐year period [16Silverstein M.D. Heit J.A. Mohr D.N. Petterson T.M. O'Fallon W.M. Melton III, L.J. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25‐year population‐based study.Arch Intern Med. 1998; 158: 585-93Crossref PubMed Scopus (0) Google Scholar], the appropriateness of comparing ESCORTE results to earlier studies is questionable. As we pointed out in our article, in the ESCORTE study mortality rates because of PE were based on both definitive PE and possible PE, judged by the investigators. Although Gianese and Prandoni [1Gianese F. Prandoni P. More on: venous thromboembolism and mortality after hip fracture: the ESCORTE study.J Thromb Haemost. 2006; 4: 1642-5Abstract Full Text Full Text PDF PubMed Google Scholar] expressed concern that fatal PE accounted for a ‘mere 0.4% of deaths’ in ESCORTE, PE was judged to be directly responsible for death in 3.9% of the cases, representing the fourth cause of death after other cardiac diseases, deterioration of general condition, and pulmonary infections. With respect to the other studies [13Pulmonary Embolism Prevention (PEP) Trial Collaborative GroupPrevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.Lancet. 2000; 355: 1295-302Abstract Full Text Full Text PDF PubMed Google Scholar, 14Freeman C. Todd C. Camilleri‐Ferrante C. Laxton C. Murrell P. Palmer C.R. Parker M. Payne B. Rushton N. Quality improvement in patients with hip fracture: experience from a multisite audit.Qual Saf Health Care. 2002; 11: 239-45Crossref PubMed Google Scholar, 15Dahl O.E. Gudmundsen T.E. Bjørnarå B.T. Solheim D.M. Risk of clinical pulmonary embolism after joint surgery in patients receiving low‐molecular‐weight heparin prophylaxis in hospital. A 10‐year prospective register of 3,954 patients.Acta Orthop Scand. 2003; 74: 299-304Crossref PubMed Google Scholar] identified by the authors as comparable to ESCORTE, these are quite heterogeneous, using various definitions of PE and completely different designs: the PEP trial [13Pulmonary Embolism Prevention (PEP) Trial Collaborative GroupPrevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.Lancet. 2000; 355: 1295-302Abstract Full Text Full Text PDF PubMed Google Scholar] was a randomized trial that assessed the benefit of aspirin use on top of ‘standard’ treatment (only 44% of patients received concomitant anticoagulation); the Freeman et al. study [14Freeman C. Todd C. Camilleri‐Ferrante C. Laxton C. Murrell P. Palmer C.R. Parker M. Payne B. Rushton N. Quality improvement in patients with hip fracture: experience from a multisite audit.Qual Saf Health Care. 2002; 11: 239-45Crossref PubMed Google Scholar] was a re‐audit of quality‐improvement conducted in only seven UK hospitals in 1997. Finally, Dahl and colleagues [15Dahl O.E. Gudmundsen T.E. Bjørnarå B.T. Solheim D.M. Risk of clinical pulmonary embolism after joint surgery in patients receiving low‐molecular‐weight heparin prophylaxis in hospital. A 10‐year prospective register of 3,954 patients.Acta Orthop Scand. 2003; 74: 299-304Crossref PubMed Google Scholar] reported findings from a prospective registry of patients from a single center over a 10‐year period from 1989 to 1998; a period during which the overall incidence of PE decreased by more than eightfold (3.4–0.4%) [16Silverstein M.D. Heit J.A. Mohr D.N. Petterson T.M. O'Fallon W.M. Melton III, L.J. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25‐year population‐based study.Arch Intern Med. 1998; 158: 585-93Crossref PubMed Scopus (0) Google Scholar]. Furthermore, in this latter study, the 1.5% rate of PE used for comparison with our results corresponded to a mean incidence per year in patients who received about 10 days of thromboprophylaxis. The lower rate of VTE in ESCORTE can therefore be explained by the fact that 70% of the patients received extended prophylaxis (more than 4 weeks’ duration). Indeed, extended duration of prophylaxis has been demonstrated to reduce the risk of symptomatic VTE by 62% in total hip or knee replacement [12Eikelboom J. Quinlan D. Douketis J. Extended‐duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta‐analysis of the randomised trials.Lancet. 2001; 358: 9-15Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] and this reduction increases to more than 80% in trials specifically addressing hip replacement surgery [17Bergqvist D. Benoni G. Bjorgell O. Fredin H. Hedlundh U. Nicolas S. Nilsson P. Nylander G. Low‐molecular‐weight heparin as prophylaxis against venous thromboembolism after total hip replacement.N Engl J Med. 1996; 335: 696-700Crossref PubMed Scopus (0) Google Scholar] or hip fracture surgery. We would like to reiterate that the ESCORTE study was a prospective, real‐life practice study that included a large number of centers to avoid major bias. It represents a ‘snapshot’ of the mortality and morbidity of hip surgery in France. An independent Critical Event Committee reviewed every episode of VTE. With respect to VTE, the observed results are in accordance with the symptomatic event rate observed in recent prospective randomized studies [3Eriksson B.I. Lassen M.R. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo‐controlled, double‐blind study.Arch Intern Med. 2003; 163: 1337-42Crossref PubMed Scopus (0) Google Scholar]. Experts in the field of postoperative VTE have concluded that symptomatic VTE is no longer a major contributor to morbidity or death in hip fracture patients in France due, in part, to the wide use of extended prophylaxis. On the other hand, we have to keep in mind that patients with hip fracture remain at a very high risk of morbidity and mortality from other causes. These causes deserve to be better understood and considered, even if they are mainly driven by the patients’ age. We would hope that ESCORTE can serve as a current practices database that can be used to develop future studies in this field.