Use Of Appropriate Prophylaxis Research Articles

Survey of U.S. Healthcare Providers to Assess Attitudes and Practices Regarding Thromboprophylaxis of Hospitalized Adult Patients

Background: Venous thromboembolism (VTE) is a leading cause of mortality among hospitalized patients, but appropriate thromboprophylaxis remains underutilized. A significant proportion of VTE associated with hospitalization occurs after discharge. We conducted a national survey of healthcare providers to explore attitudes, practices, and barriers related to thromboprophylaxis in hospitalized patients, including practices for post discharge VTE prevention. Methods: We developed a survey exploring current attitudes and practices around VTE prophylaxis in adult hospitalized patients. Healthcare providers targeted for the survey were physicians, nurses, physician assistants, and pharmacists. The survey was administered to a targeted convenience sample. Participants were recruited through social media, professional healthcare organizations, and internal medicine program directors across the US. The overarching survey areas included (1) use of appropriate prophylaxis, including perceived rates of appropriate prophylaxis at respective institutions, (2) perceived barriers to appropriate prophylaxis, (3) practices to educate about and prevent post discharge VTE events, and (4) views on use of risk assessment models (RAMs) and other strategies to improve rates of VTE prophylaxis. Since it is generally understood by the healthcare provider respondents of this survey that administration of VTE prophylaxis depends on a patient's risk, survey questions did not specify a definition for appropriate prophylaxis. We summarized data as proportions with 95% confidence intervals (CI). Results: Of 607 U.S.-based respondents, 69.9% were 40 years or younger, 55.7% were female, 68.2% were white, and 63.1% reported working in an academic hospital. Physicians comprised 70.7% of respondents, of whom 46.6% identified as trainees; among non-trainees, 49.0% had been in practice for more than 10 years. Hospital medicine was the most frequent specialty (52.1%) followed by hematology (20.8%). Nearly all respondents agreed that VTE prophylaxis is important for patient care (98.8%, 95% CI: 97.6-99.5) and that current measures are safe (92.6%, 95% CI: 90.2-94.5) and effective (93.8%, 95% CI: 91.6-95.6). Yet only 52.0% (95% CI: 47.9-56.0) of respondents perceived that hospitalized patients at their institution were on appropriate VTE prophylaxis almost all of the time. The most commonly cited reasons for patients not being on appropriate VTE prophylaxis included patient refusal (21.8%), risk of bleeding outweighs benefit (21.6%), and unclear indications (16.0%) and contraindications (17.6%) for prophylaxis. Less than half of respondents reported using institutional protocols (48.3%) or a standardized RAM (35.4%) to select patients for VTE prophylaxis and most respondents (72.3%) relied on clinical judgement to assess bleeding risk when deciding on prophylaxis (Figure 1). Respondent views on strategies that could improve VTE prophylaxis rates in hospitalized patients included integration of RAMs into electronic health records (66.6%), automatic electronic reminders (55.0%), and order sets in electronic systems (46.1%) (Figure 2). Less than 20% of respondents reported routinely educating patients about risks (15.1%, 95% CI: 12.3-18.2) and symptoms (17.9%, 95% CI: 14.9-21.2) of post-discharge VTE events, and 8.6% (95% CI: 0.06-11.1) routinely prescribe VTE prophylaxis on discharge. Respondent views on strategies that could help reduce post-discharge VTE events included using standardized risk assessments at discharge (60.0%), providing educational materials at discharge (51.2%), and including post-discharge VTE prophylaxis in discharge checklists (45.5%) (Figure 2). Conclusion: To our knowledge, this is the largest U.S. national survey to date that focuses on VTE prevention practices in hospitalized patients. VTE prophylaxis was almost universally accepted as important, safe, and effective for patients at risk for VTE. Less than half of the respondents reported using standardized protocols or RAMs to guide appropriate thromboprophylaxis administration. Discharge education regarding risks of VTE is infrequent. This national multidisciplinary survey study highlights gaps in current practices and strategies for VTE prevention in hospitalized patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Risk of disease transmission in an expanded donor population: the potential of hepatitis B virus donors.

Lack of availability of donor organs is a constant challenge that patients and providers face in transplantation. To address this shortage, donors that test positive for hepatitis B, in particular those with resolved infection, have been increasingly utilized in clinical practice. We review here the potential risks for the recipient and the advances in hepatitis B management that have made use of these donors a well tolerated and advisable proposition. As routine administration of antiviral prophylaxis in the posttransplant setting among those deemed high risk for transmission, outcomes for recipients of hepatitis B donors, including liver transplant recipients, have been comparable to uninfected donors. Universal hepatitis B nucleic acid testing of donors has also enhanced our ability to accurately inform recipients regarding transmission risk. Appropriate use of prophylaxis and careful monitoring for transmission posttransplant is key to ensuring no adverse outcomes occur. Treatment of hepatitis B has evolved over the past two decades. Expanding the donor pool with hepatitis B donors is now well tolerated, ethical, and advantageous to the transplant community at large. A clear discussion with recipients on the substantial benefit and low harm of using hepatitis B donors will lead to greater acceptance and utilization of these organs.

Venous Thromboembolism Events and Prophylaxis in Patients with Acute Myeloid Leukemia

Introduction: Thrombotic events are a frequent complication in patients with malignancy due to increased tissue factor expression and activation of hemostatic mechanisms by both host cells and cancer tissues. Patients with acute myeloid leukemia (AML) are at risk of venous thromboembolism (VTE) not only because of their malignancy but also because of prolonged hospitalizations, immobility, and the need for central venous access. Profound thrombocytopenia is an expected complication, due to myelosuppressive chemotherapy as well as from underlying marrow-infiltrative disease. This results in difficult prophylactic and treatment decisions where providers must carefully balance the risk of thrombosis and bleeding. There are no published consensus guidelines regarding appropriate use of prophylaxis in patients with leukemia.Methods: A retrospective chart review was completed on AML patients receiving induction or consolidation chemotherapy or treatment for relapsed disease admitted to the University of Virginia from October 2011 through September 2017. Patients with acute promyelocytic leukemia were excluded. Clinical data from 142 patients over a total of 667 hospital admissions were reviewed. The following data was collected: demographics (including age, sex, and race), clotting events, clot location, type of line placed, treatment of clot, and bleeding events. Bleeding events were defined according to International Thrombosis and Hemostasis criteria. χ2 analysis was performed to compare categorical values.Results: Twenty-nine of 142 (20.4%) AML patients were diagnosed with VTE. None of the patients had a prior history of clot or diagnosis of clotting disorder. Thrombosis occurred more commonly during induction therapy, 13 of the 29 events (45%), compared to other stages in their treatment (p value=0.37). Of the thromboses occurring during induction, 14 clotting events (48%) were central line associated, 4% (5/125) of thrombosis occurred in peripherally inserted central lines, 10% (5/51) in temporary internal jugular central lines and 2% (4/165) in tunneled central lines (p value=0.99).The average platelet count at the time of clot was 61 K/µl. Most patients were not on prophylaxis at the time of their clotting event (93.1% vs 6.9%; p value= <0.001). The majority of patients (19 of 29; 65.5%) were treated with therapeutic anticoagulation with heparin or low molecular weight heparin; 4 of 29 (13.8%) patients received temporary inferior vena cava filters. For those patients with a line-associated VTE, 9 of the 14 (64%) had the line removed. There was no statistically significant difference in the incidence of VTE in patient ages less than 60 years versus in older patients (55% vs 44.8%; p value=0.75).Patients who received therapeutic anticoagulation had a comparable rate of bleeding compared to patients who were not on anticoagulation (31.6% vs 40.8%; p value= 0.44). Patients who were treated for VTE (n=19) had 2 major bleeds and 4 clinically relevant non-major bleeds. Patients who did not receive treatment for their VTE event (n=10) had 1 major bleed and 3 minor bleeding events.Conclusion: Our study identified a 20.4% incidence of VTE in AML patients, occurring more frequently during induction chemotherapy and in patients without prior thrombotic history.The clots were most commonly catheter associated and the highest rate of clot occurred with temporary internal jugular lines. Importantly, we found that when patients were treated with anticoagulation, their incidence of bleed did not exceed the general incidence of bleeding (43%) seen during the time period of the analysis. Average platelet count at VTE diagnosis was 61 K/µL, which is above most institutions' thresholds for use of pharmacologic VTE prophylaxis including patients with acute leukemia. Given that only two patients in our study were receiving prophylaxis at the time of VTE and that bleeding rates were similar with full therapeutic anticoagulation, this suggests prophylaxis is important, safe, and is potentially neglected in patients with acute leukemia. This highlights an area of potential improvement in decreasing VTE in patients that can safely receive prophylaxis and is the basis for future prospective safety trials exploring the use of prophylaxis in this patient population. DisclosuresNo relevant conflicts of interest to declare.

Characteristics and Severity of Disease among 100 Cases of Imported Malaria Seen at a U.S. University Hospital, 2000–2017

Malaria acquired in endemic areas poses a substantial risk to travelers arriving in or returning to the United States. Timely diagnosis and recognition of severe illness are crucial; however, many U.S.-based clinicians lack familiarity with this disease. We conducted a retrospective review of 100 cases of malaria in adults seen at a single urban university hospital during 2000-2017. Descriptive and analytical statistics were calculated, including logistic regression modeling case severity. Most of the patients presented with Plasmodium falciparum (76%), most commonly after travel from sub-Saharan Africa (94%). Prior malaria experience was common (50%), but adherence to a prophylactic regimen was exceedingly rare (4%). Twenty-one patients had severe malaria, including 10 with cerebral malaria. Severity was predicted by high parasitemia, bandemia, hypoglycemia, and hypotension at the time of presentation. In 24 patients, the initial treatment regimen was changed, usually because of the appearance of clinical deterioration or drug toxicity. One patient required intravenous artesunate. All patients survived, although one suffered fetal loss. Among 30 patients initially evaluated at other institutions, 43% had been treated for an alternative diagnosis. The most common reasons for transfer of patients to our hospital were inadequate facilities and lack of expertise with malaria. There needs to be increased awareness among U.S.-based travelers and clinicians regarding malaria as a potentially lethal condition, emphasizing the use of appropriate prophylaxis. Our simple model of disease severity could serve frontline physicians when deciding which patients should be admitted to the intensive care unit or transferred for higher level care.

Quality Initiative to Introduce Pediatric Venous Thromboembolism Risk Assessment for Orthopedic and Surgery Patients.

Pediatric hospital-acquired venous thromboembolism (VTE) is costly, has high morbidity, and is often preventable. The objective of this quality-improvement effort was to increase the percentage of general surgery and orthopedic patients ≥10 years of age screened for VTE risk from 0% to 80%. At a freestanding children's hospital, 2 teams worked to implement VTE risk screening for postoperative inpatients. The general surgery team used residents and nurse practitioners to perform screening whereas the orthopedic team initially used bedside nursing staff. Both groups employed multiple small tests of change. Shared key interventions included refinement of a screening tool, provider education, mitigation of failures, and embedding the risk assessment task into staff workflow. The primary outcome measure, the percentage of eligible patients with a completed VTE risk assessment, was plotted on run charts. Secondary outcome measures for screened patients included the level of risk, the use of appropriate prophylaxis, and VTE events. Median weekly percentage of general surgery patients screened for VTE risk increased from 0% to 86% within 12 months, and median weekly percentage of orthopedic patients screened for VTE risk increased from 0% to 46% within 8 months. Among screened patients, the majority were at low or moderate risk for VTE and received prophylaxis in accordance with or beyond guideline recommendations. No screened patients developed VTE. Quality-improvement methods were used to implement a VTE risk screening process for postoperative patients. Using providers as screeners, as opposed to bedside nurses, led to a greater percentage of patients screened.

Intraventricular hemorrhage in neonates born from 23 to 26 weeks of gestation: Retrospective analysis of risk factors.

The study aim was to determine the incidence and analyze risk factors of IVH stage 3 and 4 in infants born before 26 weeks of gestation. A retrospective analysis of 110 preterm babies (23-26 weeks of gestation) hospitalized from 2009 to 2014 at the Department of Neonatology of Poznan University of Medical Sciences was performed. In the study group there were 29 (26.4%) children in the 23rd-24th weeks of pregnancy and 81 (73.6%) in the 25th-26th weeks of gestation. Among IVH stage 3 and 4 in neonates without prenatal steroids therapy, OR was 1.616 (1.059- 2.456; p = 0.022) for children born in the 23rd-24th week of gestation and 1.677 (1.001-2.809; p = 0.047) for children born in the 25th-26th week of pregnancy. An analysis of various risk factors revealed the chance of the appearance IVH stage 3 and 4 among neonates born in the 23th-24th and 25th-26th week of gestation rising only among those children who were treated for hypotension with catecholamines (OR 2.031 (0.269-24.21), p = 0.033 and OR 1.989 (0.224-16.55), p = 0.024). The lower the gestational age, the more frequent the risk of IVH stage 3 and 4. The use of appropriate prophylaxis of perinatal patients (steroids in all pregnant women at risk of preterm birth, limiting the indications for the use of catecholamines for hypotension treatment) reduces the incidence of severe IVH.

Intraventricular hemorrhage in neonates born before 32weeks of gestation-retrospective analysis of risk factors.

IntroductionIntraventricular hemorrhage (IVH) affects 15–20 % of babies born before 32 weeks of pregnancy. A lot of risk factors of developing IVH are known. The making appropriate recommendations for dealing with infant born less than 32 weeks of gestation aimed at reducing the incidence of IVH is still needed. The study aim was to determine the incidence and analyze risk factors of IVH stage 3 and 4 in infants born before 32 + 0 weeks of pregnancy.MethodsThe retrospective analysis of 267 preterm babies (24 to 32 weeks of gestation) hospitalized in 2011–2013 at Department of Neonatology, Poznan University of Medical Sciences was performed. The diagnosis of IVH was confirmed by ultrasound scans according to Papille criteria. Stage 3 and 4 of IVH was confirmed in 14 (25 %) newborns from 23 to 24 weeks of gestation; 21 (37.5 %) from 25 to 26 weeks of gestation; 11 (19.6 %) from 27 to 28 weeks of gestation; 9 (16.1 %) from 29 to 30 weeks of gestation; and 1 (1.8 %) from 31 to 32 weeks of gestation.ResultThe incidence of IVH stage 3 and 4 was higher in children: with less use of AST (OR 1.27; 0.62–2.61), born out of third-level hospitals (OR 2.25; 1.23–4.08), born with asphyxia (OR 3.46; 1.8–6.64), with acidosis treated with NaHCO3 (OR 6.67; 3.78–11.75), those who in the first days of life were treated for hypotension (OR 9.92; 5.12–19.21).ConclusionNo or uncompleted antenatal steroid therapy increased probability for development of severe intraventricular hemorrhage. Antenatal steroids therapy should be promoted among women at risk of a premature delivery. Hypotension therapy with catecholamines and acidosis with sodium hydrogen carbonate should be carefully considered. The use of appropriate prophylaxis of perinatal (antenatal steroids therapy women at risk of preterm birth, limiting the indications for the use of catecholamines for hypotension treatment and sodium hydrogen carbonate for acidosis therapy, limitation of preterm deliveries outside tertiary referral centeres) significantly reduces the incidence of intraventricular hemorrhage stage 3 and 4. The significance of intraventricular hemorrhage creates a need to carry out periodical analysis, at regional level, concerning its incidence, causes and effects to improve local treatment outcomes by identifying further courses of action.

Venous Thromboembolism Risk Assessment and Prophylaxis Use in Pediatric, Adolescent, and Young Adult Hematology Oncology Patients.

No widely accepted method exists to evaluate pediatric hematology oncology patients for the risk of venous thromboembolism (VTE) and the need for prophylaxis. The use of a VTE risk-assessment tool and standardized guidelines for prophylaxis could increase the use of appropriate prophylaxis and reduce the number of VTEs in patients, thereby decreasing morbidity, mortality, hospitalization, and cost. The purpose of this project was to implement and assess the compliance of a pediatric-specific VTE risk-assessment tool in hospitalized pediatric, adolescent, and young adult hematology oncology patients. From the 114 pediatric, adolescent, and young adult patients requiring assessment, 91 (80%) VTE assessments were completed and 87 (96%) were completed accurately. Eighty percent of the at-risk patients were ordered VTE prophylaxis. The use of a VTE risk-assessment tool in pediatric hematology oncology patients is a feasible way to assess patients for their risk of developing a VTE.

Review of Radiologic Infectious and Non-infectious Pulmonary Complications in Human Immunodeficiency Virus Patients

The incidence of Human Immunodeficiency Virus (HIV) has decreased from its peak in the 1980’s yet there are currently more people living with HIV than ever before. As a result of highly active antiretroviral therapy (HAART), the number of opportunistic infections has decreased, with a concurrent increase in the number of non-infectious complications, not initially observed in the initial HIV epidemic. The risk of developing HIV-related pulmonary complications is strongly influenced by the degree of immunosuppression, demographic characteristics, and the use of appropriate prophylaxis against HIV-associated opportunistic infections. This article reviews the radiographic and computed tomographic (CT) manifestations of common pulmonary infections and non-infectious pulmonary complications of HIV, and highlights the importance of clinical presentation, epidemiology and immunologic status.

Role of the Pharmacist in Achieving Performance Measures to Improve the Prevention and Treatment of Venous Thromboembolism

Current prescribing practices for venous thromboembolism (VTE) prophylaxis and treatment are suboptimal, particularly regarding the use of appropriate prophylaxis in accordance with evidence-based guidelines. Failure to prevent avoidable VTE is associated with a substantial clinical and economic burden, due not only to the initial event, but also to VTE recurrence and long-term sequelae. Quality improvement initiatives such as the Surgical Care Improvement Project, the Centers for Medicare and Medicaid Services, the National Quality Forum, and The Joint Commission have developed performance measures to address the shortfall and improve adherence with best-practice recommendations. Several studies have highlighted the benefits of pharmacist-led anticoagulation services for reducing the occurrence of VTE and bleeding complications while reducing excess hospitalization and health care costs. By assuming responsibility for anticoagulation management, pharmacists can ensure that at-risk patients receive the correct drug at the correct dose for the correct duration, from initial presentation to outpatient follow-up. Increasing continuity of care in this manner will ultimately improve patient outcomes and reduce costs. Pharmacists can also play a key role in helping hospitals achieve performance measures by aiding in the development and implementation of local VTE guidelines, policies, and other quality improvement initiatives; by helping to establish critical pathways with protocols; and by providing valuable education for other health care professionals and patients alike. Pharmacists are in an ideal position to facilitate achievement of VTE-related performance measures and can thus substantially contribute to the much-needed improvement in current VTE prevention and care.

A clinical decision support system for venous thromboembolism prophylaxis at a general hospital in a middle-income country

OBJECTIVE: To determine the impact that implementing a combination of a computer-based clinical decision support system and a program of training seminars has on the use of appropriate prophylaxis for venous thromboembolism (VTE). METHODS: We conducted a cross-sectional study in two phases (prior to and after the implementation of the new VTE prophylaxis protocol) in order to evaluate the impact that the combined strategy had on the use of appropriate VTE prophylaxis. The study was conducted at Nossa Senhora da Conceição Hospital, a general hospital in the city of Porto Alegre, Brazil. We included clinical and surgical patients over 18 years of age who were hospitalized for ≥ 48 h. The pre-implementation and post-implementation phase samples comprised 262 and 261 patients, respectively. RESULTS: The baseline characteristics of the two samples were similar, including the distribution of patients by risk level. Comparing the pre-implementation and post-implementation periods, we found that the overall use of appropriate VTE prophylaxis increased from 46.2% to 57.9% (p = 0.01). Looking at specific patient populations, we observed that the use of appropriate VTE prophylaxis increased more dramatically among cancer patients (from 18.1% to 44.1%; p = 0.002) and among patients with three or more risk factors (from 25.0% to 42.9%; p = 0.008), two populations that benefit most from prophylaxis. CONCLUSIONS: It is possible to increase the use of appropriate VTE prophylaxis in economically constrained settings through the use of a computerized protocol adhered to by trained professionals. The underutilization of prophylaxis continues to be a major problem, indicative of the need for ongoing improvement in the quality of inpatient care.

Choice of drugs in the treatment of chronic hepatitis B in pregnancy

The selection of antiviral drugs for chronic hepatitis B (CHB) treatment in pregnancy is very difficult since none of the drugs have been approved for use in pregnancy. Transmission from mother to newborn remains the most frequent route of infection in mothers with high viral load and positive hepatitis B e antigen status, even with the use of appropriate prophylaxis with hepatitis B virus (HBV) immunoglobulin and HBV vaccination. We read from the article written by Yi et al that lamivudine treatment in early pregnancy was safe and effective. However, we could not understand why adefovir dipivoxil (ADV) was used in three pregnancy cases, since ADV has been classified as pregnancy category C. In pregnancy, telbivudine or tenofovir should be selected when the treatment of CHB is necessary, since these drugs have been classified as Food and Drug Administration pregnancy risk category B.

Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study.

The aim of the present analysis from the epidemiologic international day for the evaluation of patients at risk for venous thromboembolism (VTE) in the acute hospital care setting (ENDORSE) study was to evaluate the prevalence of VTE risk in acute care hospitals and the proportion of at-risk medical and surgical patients who receive recommended prophylaxis in Switzerland. All patients (age >or=40 years) admitted to a medical ward or those (age >or=18 years) admitted to a surgical ward in ten randomly selected Swiss hospitals were assessed for risk of VTE. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and to determine whether patients were receiving recommended thromboprophylaxis. 2000 patients were eligible; of these 1153 (58%) were in surgical wards, and 847 (42%) in medical wards. According to the ACCP criteria, the proportion of surgical patients at VTE risk was similar in Switzerland (68%, between hospital range 48-86%) in comparison to the global ENDORSE study (64%) (p = 0.296). The rate of at-risk medical patients was lower in Switzerland (21%, range 3-44%) than in the global study (42%) (p <0.001). The proportion of at-risk surgical patients with ACCP-recommended VTE prophylaxis was higher in Switzerland (81%, between-hospital range 76-93%) than in the global study (59%) (p <0.001). Among medical patients at risk, the use of recommended thromboprophylaxis was higher in Switzerland (61%, between-hospital range 0-84%) than in the global ENDORSE (40%) (p <0.001). However 56% of the patients with cancer, 41% with major trauma, and 29% undergoing vascular surgery did not receive any recommended prophylaxis. Among surgical patients at risk, the use of ACCP-recommended prophylaxis was lower in academic (77%) vs. non-academic (86%) institutions (p = 0.0025). In Switzerland, although the rate of recommended thromboprophylaxis is higher than in many countries, it is still improvable in medical patients at risk according to the ACCP guidelines. Consequently, hospital wide strategies for systematic risk factor assessment and implementation of practical tools to ensure appropriate use of prophylaxis in patients at VTE risk are required.

Results of ENDORSE-2-HUNGARIA study. Repeated assessment of the prevalence of venous thromboembolism risk and prophylaxis in acute hospital care setting

ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study in 2006, was a multinational cross-sectional survey designed to assess the prevalence of venous thromboembolism (VTE) risk in the acute hospital care setting, and to determine the proportion of at-risk patients who receive appropriate prophylaxis. From the 358 randomly selected hospitals across 32 countries in the global registry, 9 Hungarian centers were included. According to the Hungarian results, the use of appropriate prophylaxis was more common in surgical patients but much less common in medical patients comparing to the worldwide average. ENDORSE 2-HUNGARY was a local survey to compare the prophylactic habits after two years and two months time period. In both surveys, the 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess venous thromboembolism risk and to determine whether patients were receiving recommended prophylaxis. The one day survey ENDORSE 2-HUNGARY was repeated beside seven already audited hospitals, and in two newly recruited hospitals. A total of 886 patients were assessed for thrombosis risk on the basis of hospital chart review. Of these patients 59.0% (N=523) were judged at risk for VTE, including 100% (N=327) surgical and 35.1% (N=196) medical patients. 67.9% (N=355) of the total at-risk patients received ACCP-recommended VTE prophylaxis. Among surgical patients, 84.4% (N=276) received recommended prophylaxis compared with 40.3% (N=79) of medical patients. Results of the ENDORSE in 2006 and 2009 were compared, as well. The rate of appropriate prophylaxis use in at-risk patients did not changed significantly in surgical patients, however, a significant, 43.9% increase was found in medical patients (p=0.002), that proves the success of lectures presenting the facts and focusing to increase medical prophylaxis during the time period between the two studies. 59.7% of at-risk medical patients and 15.6% of surgical patients were unprotected against thrombosis in 2009. We should further increase the rate of at-risk patients receiving appropriate prophylaxis. We should reinforce the rationale for the increase of awareness of VTE risk in hospitalized medical patients, and to enhance the prophylaxis practice among healthcare professionals.

Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study.

The aim of the present analysis from the epidemiologic international day for the evaluation of patients at risk for venous thromboembolism (VTE) in the acute hospital care setting (ENDORSE) study was to evaluate the prevalence of VTE risk in acute care hospitals and the proportion of at-risk medical and surgical patients who receive recommended prophylaxis in Switzerland. All patients (age >or=40 years) admitted to a medical ward or those (age >or=18 years) admitted to a surgical ward in ten randomly selected Swiss hospitals were assessed for risk of VTE. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and to determine whether patients were receiving recommended thromboprophylaxis. 2000 patients were eligible; of these 1153 (58%) were in surgical wards, and 847 (42%) in medical wards. According to the ACCP criteria, the proportion of surgical patients at VTE risk was similar in Switzerland (68%, between hospital range 48-86%) in comparison to the global ENDORSE study (64%) (p = 0.296). The rate of at-risk medical patients was lower in Switzerland (21%, range 3-44%) than in the global study (42%) (p <0.001). The proportion of at-risk surgical patients with ACCP-recommended VTE prophylaxis was higher in Switzerland (81%, between-hospital range 76-93%) than in the global study (59%) (p <0.001). Among medical patients at risk, the use of recommended thromboprophylaxis was higher in Switzerland (61%, between-hospital range 0-84%) than in the global ENDORSE (40%) (p <0.001). However 56% of the patients with cancer, 41% with major trauma, and 29% undergoing vascular surgery did not receive any recommended prophylaxis. Among surgical patients at risk, the use of ACCP-recommended prophylaxis was lower in academic (77%) vs. non-academic (86%) institutions (p = 0.0025). In Switzerland, although the rate of recommended thromboprophylaxis is higher than in many countries, it is still improvable in medical patients at risk according to the ACCP guidelines. Consequently, hospital wide strategies for systematic risk factor assessment and implementation of practical tools to ensure appropriate use of prophylaxis in patients at VTE risk are required.

Key Articles and Guidelines for the Prevention of Venous Thromboembolism

Venous thromboembolism (VTE) is an important medical problem that affects millions of patients each year. With appropriate prophylaxis, many of these thromboembolic events can be prevented. Although strong evidence supporting VTE prophylaxis spans several decades, several large American and global registries have documented very poor use of appropriate prophylaxis. Because of increasing regulatory requirements, hospitals nationwide are in the process of developing documentation of appropriate VTE prophylaxis programs for both surgical and medical patients. A wide range of clinicians must understand what constitutes appropriate VTE prophylaxis in various patient populations. With the existence of numerous pharmacologic agents, abundance of data from major clinical trials, and several nationally recognized clinical guidelines, compiling the needed reference material to make evidence-based decisions on appropriate VTE prophylaxis can be difficult for clinicians. Therefore, we provide a bibliography of key articles and guidelines related to the prevention of VTE in various patient groups. We hope this compilation will serve as a resource for pharmacists, physicians, nurses, residents, and students responsible for the care of patients who may be at risk for VTE.

Appropriate VTE Prophylaxis Is Associated with Lower Direct Medical Costs among Medical and Surgical Patients in the United States.

Introduction: Patients hospitalized with cancer, chronic heart failure (CHF), orthopedic surgery, lung disease or severe infectious disease (SID) are at a high risk of developing venous thromboembolism (VTE). However, the appropriate use of prophylaxis can reduce the burden of VTE and lower VTE-associated costs. This retrospective cohort study investigated the adequacy of VTE prophylaxis received by US hospitalized at-risk patients and compares the total direct medical costs of appropriate and partial prophylaxis.Methods: Patient discharges were selected from the Premier Perspective™ Database if they had a primary diagnosis of cancer, CHF, orthopedic surgery, lung disease, or SID, and were admitted between January and December 2003 (index hospitalization), were aged ≥40 years, and received some form of thromboprophylaxis based on American College of Chest Physicians (ACCP) guideline recommendations. Patients who died during the index hospitalization, transferred to another facility, received multiple classes of thromboprophylactic drugs, or received alternative prophylactic agents not recommended by the ACCP were excluded. Appropriate prophylaxis was defined as an ACCP-recommended prophylaxis option at the recommended dose and for the recommended duration. Partial prophylaxis was defined as receiving an ACCP-recommended prophylaxis option, but at an incorrect dose or for an insufficient duration. Total hospital costs were collected and mean costs are reported for discharges receiving appropriate and partial prophylaxis. Multivariate analysis (generalized linear model) was performed for hospitalization costs to control for differences in baseline and demographic covariates (including age, length of stay, and severity of illness) between groupsResults: A total of 703,084 discharges met the inclusion criteria, of whom 22.3% received appropriate prophylaxis and 77.7% received partial prophylaxis. The median length of hospital stay was 7 days in appropriate prophylaxis discharges and 8 days in partial prophylaxis discharges. Higher unadjusted total direct hospital costs were seen in discharges that received partial prophylaxis ($17,712) than in discharges receiving appropriate prophylaxis ($15,458). Following multivariate analysis to adjust for differences between groups, the total hospital costs remained $2,050 less in the appropriate prophylaxis group. Furthermore, appropriate prophylaxis was associated with a reduced cost in all medical conditions except for orthopedic surgery (Table 1).Conclusions: VTE prophylaxis practices continue to be suboptimal; patients at risk of VTE and receiving a form of ACCP-recommended prophylaxis are nearly 3.5 times more likely to receive partial, inappropriate prophylaxis than fully appropriate prophylaxis. Furthermore, the total direct medical cost of patients receiving appropriate prophylaxis was lower than for those receiving partial prophylaxis. Appropriate prophylaxis makes sense not only from a efficacy or quality of care perspective, but also from an economic perspective based on the results of our study.Table 1. Hospital costs associated with appropriate or partial prophylaxis (generalized linear model)DiagnosisnnMean total cost, $ (95% CI)PartialAppropriatePartialCancer16,34273,65411,384 (11,328–11,441)12,582 (12,544–12,620)Orthopedic6,8179,27215,214 (14,943–15,491)14,618 (14,371–14,868)SID93,743323,71012,836 (12,810–12,862)14,765 (14,735–14,794)Lung Disease22,03382,70214,045 (13,989–14,101)15,367 (15,337–15,398)CHF17,96356,8484,447 (4,420–4,656)5,486 (5,459–5,514)All156,898546,18614,765 (14,735–14,794)16,815 (16,798–16,831)

Venous Thromboembolism Risk and Prophylaxis Practices in Surgical Patients with Active Cancer: Findings from the Global ENDORSE Survey.

Introduction : Cancer patients undergoing surgery have double the risk for VTE compared with non-cancer patients (Thromb Haemost 2003; 90:446–55). Current ACCP guidelines advocate the use of VTE prophylaxis in patients with active malignancy undergoing major surgical procedures. The recent ENDORSE survey reported that globally, 64% of patients admitted to surgical wards were at risk for VTE, and only 59% of these received ACCP-recommended prophylaxis (Lancet 2008; 371:387–94). In this subanalysis of ENDORSE, we evaluated the prevalence of VTE risk and prophylaxis practices in surgical patients with active malignancy.Methods: The ENDORSE study evaluated data from 30,827 patients admitted to surgical wards in 358 hospitals across 32 countries (Lancet 2008; 371:387–94). The influence of active malignancy on VTE risk and prophylaxis use was assessed in patients who had undergone abdominal, urological or gynecological surgery. Patient data were grouped and analyzed according to whether the surgery was related to a cancer diagnosis (surgery for cancer) or performed in patients without a cancer diagnosis (no cancer). Risk for VTE and use of appropriate prophylaxis was evaluated according to the 2004 ACCP-guidelines (Chest 2004; 126:338S–400S). Bleeding risk factors considered sufficient to present a contraindication to anticoagulant use included intracranial hemorrhage, bleeding at hospital admission, presence of a known bleeding disorder and clinically relevant hepatic impairment.Results: Of the 30,827 patients in surgical wards evaluated in ENDORSE, 18,461 had undergone major surgery as of the date of the survey, including 6172 patients who had abdominal, urological or gynecological operations and were considered at risk for VTE. All patients with a cancer diagnosis who underwent these types of surgery were considered at-risk for VTE, including 1767 patients whose surgical procedure was related to their diagnosis and 101 patients who underwent surgery unrelated to cancer. The proportion of patients receiving any ACCP-recommended prophylaxis ranged from 60% in patients undergoing surgery for urologic cancer to 86% in patients undergoing surgery for rectosigmoid cancer. Patients who had surgery related to their cancer had a higher rate of ACCP-recommended prophylaxis use, compared with patients who underwent surgery with no cancer diagnosis (Table). The proportion of patients considered to have bleeding risk sufficient to present a contraindication to anticoagulant use was 10.4% (surgery for cancer) and 10.9% (no cancer; Table). Fewer patients without a cancer diagnosis received anticoagulant prophylaxis, compared with those undergoing cancer-related surgery (Table).Table: VTE prophylaxis practice according to the presence of active malignancy.Surgery typeAt-risk receiving ACCP-recommendedprophylaxis n/N (%)Contrain-dications to anticoagulant use, n (%)Anticoagulant alone, n (%)Mechanical alone, n (%)Both, n (%)Surgery for cancer (N=1767)1295/1767 (73.3)183 (10.4)820 (46.4)136 (7.7)412 (23.3)No cancer (N=5097)2495/4304* (58.0)470 (10.9)1455 (33.8)426 (9.9)762 (17.7)*4304 of 5097 patients without a cancer diagnosis were considered at risk for VTEConclusion: The use of any type of ACCP-recommended VTE prophylaxis varied according to the type of cancer for which the surgery was performed. Although all cancer patients who undergo abdominal, urological or gynecological surgery are at risk for VTE, the results suggest that up to 30% of cancer patients where surgery is performed related to a cancer diagnosis do not receive ACCP-recommended prophylaxis. Less than 11% of patients who had surgery regardless of whether it was related to a cancer diagnosis had a bleeding risk sufficient to present a contraindication to anticoagulant use. These findings suggest that despite the existence of clear evidence-based guidelines, the use of VTE prophylaxis in cancer patients remains suboptimal.

Clinical Predictors of Prophylaxis Use Prior to the Onset of Acute Venous Thromboembolism in Hospitalized Patients: Swiss Venous ThromboEmbolism Registry (SWIVTER)

Background: Venous thromboembolism (VTE) prophylaxis among hospitalized patients remains underutilized. We investigated the use of appropriate prophylaxis and predictors for using prophylaxis prior to the onset of acute VTE.Methods: In 14 academic and non-academic Swiss hospitals, 567 consecutive patients (306 medical and 261 surgical patients) with objectively confirmed acute VTE and hospitalization within 30 days prior to the VTE event were enrolled. Data on acute and chronic comorbidities, VTE risk factors, and prophylaxis use prior to VTE were prospectively recorded.Results: Among the 567 patients (62±16 years), deep vein thrombosis (DVT) alone was diagnosed in 222 (39%), acute pulmonary embolism (PE) in 218 (38%), and PE plus DVT in 127 (22%). Overall, prophylaxis was used in 329 (58%) patients prior to the VTE event. Among the medical patients, 146 (48%) received prophylaxis, and among the surgical patients, 183 (70%) received prophylaxis (p <0.001). The indication for prophylaxis was present in 262 (86%) medical patients and in 217 (83%) surgical patients. Among the patients with an indication for prophylaxis, 135 (52%) of the medical patients and 165 (76%) of the surgical patients received prophylaxis (p <0.001). Admission to the intensive care unit (OR 3.28, 95% CI 1.94–5.57), recent surgery (OR 2.28, 95% CI 1.51–3.44), bed rest >3 days (OR 2.12, 95% CI 1.45–3.09), obesity (OR 2.01, 95% CI 1.03–3.90), prior DVT (OR 1.71, 95% CI 1.31–2.24), and prior PE (OR 1.54, 95% CI 1.05–2.26) were independent predictors of prophylaxis. In contrast, cancer (OR 1.06, 95% CI 0.89–1.25), age (OR 0.99, 95% CI 0.98–1.01), acute heart failure (OR 1.13, 95% CI 0.79–1.63), and acute respiratory failure (OR 1.19, 95% CI 0.89–1.59) were not predictive of prophylaxis.Conclusions: Although an indication for prophylaxis was present in most patients who suffered acute VTE as a complication during or shortly after hospitalization, almost half did not receive any form of prophylaxis. Future effort should focus on the improvement of prophylaxis in hospitalized patients, particularly in patients with cancer, acute heart or respiratory failure, and in the elderly.

Antikoagulation bei Vorhofflimmern

Atrial fibrillation is the most common arrhythmia in the elderly and is associated with substantial morbidity and mortality, mostly due to the consequences of thromboembolism. Anticoagulation reduces the risk of stroke and death considerably, the risk reduction depending on the patient's absolute risk. Although there is modest benefit from acetylsalicylic acid, randomized trials have shown that it is consistently and substantially less effective than vitamin K antagonists. These benefits must be balanced against an increased risk of bleeding. In addition, warfarin therapy imposes a variety of lifestyle constraints, including frequent blood test monitoring and, possibly, dietary modification, and is associated with a number of drug interactions. Careful assessment of the absolute risk of stroke on the one hand and bleeding complications on the other hand will guide the use of appropriate prophylaxis against thromboembolism and its consequences.