Use Of Venous Thromboembolism Prophylaxis Research Articles

Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients

Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.

Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California.

Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.

The effect of obligatory Padua prediction scoring in hospitalized medically ill patients: A retrospective cohort study.

Venous thromboembolism (VTE) is considered a preventable cause of mortality. The evidence for the benefit of VTE prophylaxis in acute medical patients is non-conclusive. Meta-analysis of RCTs failed to demonstrate reduction of all-cause mortality, while showing higher risk of bleeding. The Israeli Ministry of Health has instructed to assess all acute medical patients for the risk for VTE using the Padua Prediction Score, without mandating prophylaxis. To evaluate the effect of filling the Padua score on clinical outcomes and VTE prophylaxis rates. Retrospective Study was performed in Israel during the years 2014-2017. The participants were divided to Padua compliance vs non-compliance group. Primary outcome: 30-day mortality. Secondary outcomes: 90-day incidence of VTE and suspected major bleeding. A propensity-weighted logistic multiple regression was performed. 18,890 patients were included in the study. The fulfillment of the Padua score was associated with an increased use of VTE prophylaxis, OR 1.66 (95% CI 1.49-1.84). However, there was no reduction of mortality or VTE events, OR 1.13 (95% CI 0.97-1.31) and OR 1.22 (95% CI 0.79-1.8) respectively. Hospitalizations related to hemoglobin decrease were not statistically different between the two groups. Padua score for the assessment of VTE risk in medical wards was associated with higher administration of pharmacological prophylaxis without reduction in VTE or mortality rate. Its usage should be reassessed as a performance measure.

Venous Thromboembolism in Patients with Inflammatory Bowel Disease.

Patients diagnosed with inflammatory bowel disease (IBD), which encompasses Crohn's disease and ulcerative colitis, experience chronic inflammation of the gastrointestinal tract. Those with IBD face a higher risk of developing venous thromboembolism (VTE) compared to individuals without IBD. This escalated risk is associated with various factors, some modifiable and others non-modifiable, with disease activity being the primary concern. Interestingly, Janus Kinase inhibitors approved for the treatment of IBD may be associated with an increased risk of VTE but only in patients that have other underlying risk factors leading to an overall increased VTE risk. Several recognized medical societies have recommended the use of VTE prophylaxis for hospitalized individuals with IBD. The association between VTE and IBD and the need for pharmacologic prophylaxis remains under-recognized. Increased awareness of this complication can hopefully protect patients from a potentially deadly complication.

An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients

The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.

Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus.

This article assesses the application of the Royal College of Obstetricians and Gynaecologists (RCOG) venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of systemic lupus erythematosus (SLE). This is a secondary analysis of an ongoing patient registry of women with SLE from 2016 to 2022. There were 49 SLE patients with 55 pregnancies using the Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of "active SLE" by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher's exact test, chi-square test, and Mann-Whitney U test with significance defined as p < 0.05. In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n = 4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥3. Only 35.7% (n = 5) of pregnancies in DORIS remission, but with 3 points for non-SLE-related VTE risk factors (n = 14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score < 3 after assessing all risk factors, 15% (n = 3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy. These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present. · Those with SLE are at increased risk for VTE postpartum.. · VTE prophylaxis should be instituted when clinically appropriate.. · Caution should be exercised in broadly assigning disease activity for SLE diagnosis only.. · This study supports VTE prophylaxis use in postpartum patients with SLE..

Safety and efficacy of venous thromboembolism prophylaxis in patients with cirrhosis: A systematic review and meta-analysis.

Patients with cirrhosis are considered in a haemostatic balance, though weaker than in normal subjects. In these patients, however, the use of pharmacological prophylaxis for venous thromboembolism (VTE) remains controversial. Therefore, in this study, we aimed to assess the safety and efficacy of VTE prophylaxis in patients with cirrhosis. We conducted a systematic review of studies reporting the occurrence of bleeding and VTE events in patients with cirrhosis, and controls, undergoing VTE prophylaxis. Meta-regression analysis was conducted to further explore the determinants of heterogeneity in the study of the occurrence of either bleeding or VTE events. In a total of 10 studies, including 5712 patients, of which 2330 undergoing VTE prophylaxis, bleeding (n = 5513) and VTE events occurred in 8.2% and 2.8% patients respectively. A total of 2963 and 3162 patients were included from low-risk of bias studies in bleeding and VTE analysis respectively: while administration of VTE prophylaxis did not seem to reduce VTE (OR = 1.07, CI 0.39-2.96, p = .89), importantly prophylaxis was not associated with increased bleeding risk (OR = 0.56, CI 0.20-1.59, p = .27). Meta-regression analysis showed that no parameter significantly influenced the heterogeneity of data regarding bleeding or VTE events. In patients with cirrhosis, current evidence is insufficient to advise for or against the use of VTE prophylaxis, mainly due to lack of quality and homogeneity of available data. However, its use does not appear to be associated with a significant bleeding risk. Adequately designed studies are required to provide a measure of its overall utility.

Assessment-based management of placenta-mediated pregnancy complications: Pragmatism until a precision medicine approach evolves.

The management of pregnant women with thrombophilia and a history of gestational vascular complications remains debatable. Treatment of the latter is often based on clinical outcome rather than disease mechanism. While the use of venous thromboembolism prophylaxis in pregnancy is recommended for those at increased risk, the ability of anticoagulant and/or antiplatelet agents to lower the risk of placenta-mediated complications in this clinical setting remains controversial. The available guidelines are inconsistent in some situations, which reflects the limited evidence base. This review critically discusses risk assessment models (RAMs) and management strategies of women with thrombophilia and pregnancy complications, using clinical vignettes. RAMs, taking into account obstetric and thrombotic history as well as thrombophilia status, could drive a precision medicine approach, based on disease mechanism, and guide individual therapeutic interventions in high-risk clinical settings.

Venous Thromboembolism Prophylaxis in Pediatric Inflammatory Bowel Disease Patients Hospitalized With a Central Line.

Patients hospitalized with inflammatory bowel disease (IBD) have increased risk of venous thromboembolism (VTE). The aim of this study was to determine whether the adoption of a VTE protocol would change rates of medical VTE prophylaxis (low molecular weight heparin) in patients with IBD and a central venous catheter (CVC), while subsequently decreasing the incidence of VTE in this population. A protocol for VTE prophylaxis in IBD was established in March of 2018. Every patient hospitalized with an IBD flare and central venous access from March 2013 to March 2020 was identified. Study data, including patient demographics, rates of Doppler ultrasound (US), and rates of VTE were collected using International Classification of Diseases (ICD)-10 codes, CPT codes, and chart review retrospectively. Determination of an IBD flare was based on physician global assessment. Groups were compared with independent-sample t tests and chi-squared tests. A total of 313 hospitalizations across 187 different patients were identified that met criteria including IBD and central venous access. VTE prophylaxis increased from 5.24% (n = 12) prior to the intervention to 63.10% (n = 53) after the intervention [chi-square (1, N = 313) = 125.0192, P < 0.001]. Rate of Doppler US increased from 9.17% (n = 21) prior to the intervention to 17.86% (n = 15) after the intervention [chi-square (1, N = 313) = 4.5562, P < 0.05]. Diagnosis of VTE increased from 0.87% (n = 2) prior to the intervention to 7.14% (n = 6) after the intervention [chi-square (1, N = 313) = 9.6992, P < 0.01]. There were no significant differences in the demographic characteristics pre- versus post-intervention. Rates of Doppler US and VTE prophylaxis use increased significantly after implementation of a VTE protocol. Rates of VTE diagnosis also increased, though we suspect this may be due to missed diagnoses prior to implementation of the protocol and increased risk awareness after the protocol was established.

Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma.

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.

Risk of Venous Thromboembolism in Multiple Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplant

Introduction: Venous thromboembolism (VTE) is a common complication that could affect multiple myeloma (MM) patients. Previous studies suggested the incidence of VTE in MM patients not on VTE prophylaxis to be as high as 10.7% in the peri-transplant period. Usage of antiplatelet or anticoagulant VTE prophylaxis is often a challenging clinical decision especially in patients with profound thrombocytopenia. Here, we aimed to explore the incidence and risk factors for VTE in MM patients undergoing AHCT. Methods: The electronic medical records of all MM patients who underwent AHCT at Cleveland Clinic between January 1st, 2011 and January 15th, 2021 were reviewed. We evaluated the incidence and type of venous thrombosis occurring in the immediate peri-transplant period, defined as extending from the start of stem cell apheresis up to 30 days post-AHCT. Baseline patient, demographic, disease, and transplant factors were evaluated to analyze risk factors for VTE occurrence within the studied period. Statistical Package for Social Sciences (SPSS) was used for statistical analysis. Results: A total of 493 patients with available records were included in our study. The median age was 61.4 years (range 33.1-77.7 years) at the time of AHCT with a male preponderance of 59%. Symptomatic VTE was recorded in 23 events involving 17 patients (3.5%) within the defined peri-transplant period, of which 34.8% of the events occurred between the start of stem cell apheresis and the date of transplant (i.e. day 0). Around 34.8% of VTE events, involving 6 (35.3%), patients occurred during hospitalization for the transplant procedure. All VTEs were non-catheter related, and most were lower extremity deep venous thromboses (DVT) (52.2%), followed by pulmonary emboli (17.4%), DVT of upper extremities (13%), internal jugular thromboses (13%) and superficial vein thrombosis (4.4%). Of the 17 VTE patients, 41% had history of previous VTE prior to the defined peri-transplant period, 88.2% were recently on immunomodulatory drugs (IMiD), 76.5% were on either antiplatelet (41.2%) or anticoagulant (53%) therapy or both (17.7%), while 23.5% were on none. Most of the VTE patients were never smokers (70.6%), while the rest (29.4%) were ex-smokers. Of note, 35.3% of VTE patients had thrombocytopenia (Platelets <150 x109/L) but median platelet count of 184 x109/L. Patients who developed VTE were of similar age (median 62.1 vs 61.4 years, P=0.9) but had a higher female preponderance (64.7 vs 40.1%, P=0.04) compared to those who did not. In addition, they had similar albumin levels at diagnosis (75 vs 71.7% ≥ 3.5 g/dL, P=0.8), similar cytogenetic risk categorization (high risk in 35.3 vs 25.8%, P=0.4), ISS stages (P=0.5), disease remission status prior to AHCT (P=0.3), mobilization regimens (G-CSF + Plerixafor in 88.2 vs 88.2%, P=0.1), and recent IMiD use (88.2 vs76.7, P=0.26) (Table 1). However, VTE patients were more likely to have IgG MM (70.6 vs 62%, P=0.06), Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) ≥1 (100 vs 81.1%, P=0.05), infection at AHCT (12.5 vs 3.2%, P=0.05), longer length of AHCT hospital stay (median 17 vs 14.9 days, P<0.0001), and had higher prevalence of prior history of VTE (41.2 vs 11.6%, P<0.0001) (Table 1). With regards to prophylaxis therapy, VTE patients were less likely to be on antiplatelets (41.2 vs 65.6%, P=0.039), were on similar prophylactic anticoagulation (11.8 vs 19.5%, P=0.42), but were more likely to be on therapeutic anticoagulation (41 vs 14%, P=0.002) compared to non-VTE pts, suggesting a higher impact of a history of prior VTE than therapeutic anticoagulation on recurrence of VTE during the studied time period. Among patients with no history of previous VTE, non-VTE patients were more likely to be on either antiplatelet or prophylactic anticoagulation (82.6 vs 50%, P=0.02). Interestingly, no difference was seen in the incidence of VTE with antiplatelet vs prophylactic anticoagulation in patients without history of previous VTE (1.86 vs 0%, P=0.9). Moreover, among those with a history of previous VTE, the addition of antiplatelets to therapeutic anticoagulation did not significantly lower the risk of VTE recurrence in the studied time period (9 vs 16%, P=0.9). Conclusion: The use of VTE prophylaxis among MM patients undergoing AHCT may lower its incidence. The main risk factors for VTE are female sex, history of previous VTE, infections at AHCT, HCT-CI ≥1, and longer hospital stay. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost

Background: Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. Hypothesis: Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. Study Design: Economic and decision analysis; Level of evidence, 3. Methods: The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A “break-even” analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. Results: The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. Conclusion: Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.

Venous Thromboembolism Prophylaxis Use by Pediatric Orthopedic Surgeons in Canada for the Pediatric Orthopedic Surgical Population.

Introduction A novel pediatric venous thromboembolism (VTE) screening tool was implemented in 2016 at the Izaak Walton Killam (IWK) Health Centre, which safely reduced the use of thromboprophylaxis by 47.9% with no increase in VTE in the pediatric orthopedic surgical population (POSP). There is presently no data on the current practices or protocols for VTE prophylaxis for POSP in Canada. The present survey was designed to assess current practices regarding VTE prophylaxis for POSP in Canada. Methods After research ethics board (REB) approval, a 22-question survey was administered electronically to all Canadian Pediatric Orthopedic Group (CPOG) members. The survey contained questions on respondent demographics and background, current VTE prophylaxis practices and experiences including indications for prophylaxis, the existence of VTE protocols, and interest in utilizing VTE protocols. Descriptive statistical analyses and analysis of variance (ANOVA) were completed on the survey responses. Results Of the 100 CPOG members, 49 (49%) responded. Most respondents (51%, n=25/49) practice in Central Canada, 39% (n=19/49) practice in Western Canadian provinces, and a smaller portion practice in Atlantic Canada (10%, n=5/49). Of the respondents,43% (n=21/49) indicated that they use pharmacologic VTE prophylaxis in their practice, and 93% (n=27/29) stated that specific risk factors are indications of initiating pharmacologic VTE prophylaxis. Additionally, 57% (n=16/28) did not have a defined protocol for VTE prophylaxis, and 18% (n=5/28) were uncertain if they do. Of the respondents, 85% (n=22/26) were open to utilizing a VTE prophylaxis screening tool, and 12% (n=3/26) were uncertain if they would be. Conclusion This study has demonstrated that a uniform protocol for VTE prophylaxis does not exist in most Canadian centers, despite its need. There is nationwide interest in adopting a perioperative VTE prophylaxis screening tool to optimize pharmacologic thromboprophylaxis use in POSP. The goal of future research is the national implementation and standardization of such a screening tool through collaboration in a multicenter study.

S813 Venous Thromboembolism Rates Among Patients Hospitalized for Inflammatory Bowel Disease Exacerbation: A Time Trend Analysis of the National Inpatient Sample

Introduction: Inflammatory bowel disease (IBD) flare increases risk of venous thromboembolism (VTE) events, especially during hospitalization. Guidelines, support the use of VTE prophylaxis for these patients, but it is unclear if this has impacted rates of VTE. Our goal was to assess time trends of VTE rates among IBD admissions. Methods: Patients hospitalized from 2007 to 2019 were identified in the National Inpatient Sample (NIS) by International Classification of Diseases (ICD), 9th and 10th Revision codes. Patients with IBD flare were selected by either a) a primary diagnosis of Crohn’s disease (CD) or Ulcerative colitis (UC) or b) a secondary diagnosis of CD or UC with a primary diagnosis of a gastrointestinal manifestations of IBD: abdominal pain, anemia, malnutrition, or dehydration. Hospitalizations for VTE were identified by those with a primary or secondary diagnosis of VTE. Patients with chronic thrombosis or prior VTE were excluded. Incidence of VTE was assessed by disease type (CD vs. UC) and by racial/ethnic identification: white, black, Hispanic, Asian or Pacific Islander, Native American, other. Cochran-Armitage trend tests were used for binary variables while trends for variables with reported mean averages used linear regression. The Rao-Scott design-adjusted chi-square test was used to evaluate the association between binary variables and the diagnosis of IBD in patients with VTE. Results: 131,541 weighted cases were admitted for an IBD flare complicated by VTE; 73,530 had CD and 58,011 had UC, Table. VTE prevalence was higher among patients with UC compared to CD, 42.6 vs. 30.7 per 1,000 hospitalizations, respectively. Over the study period, the rates of VTE in IBD hospitalizations increased, from 3.58% to 4.62% for UC (p< 0.0001) and from 2.22% to 3.66% for CD (p< 0.0001), Figure 1a. Black patients with IBD were found to be at higher risk of VTE (aOR 1.075, p=0.002), while Hispanic and Asian / Pacific Islanders had lower risk for developing VTE when compared to Whites (aOR 0.873 and 0.658, respectively; p< 0.0001). Aside from Hispanic and Native American UC patients, all races and ethnicities had increasing trends of VTE during the study period, Figure 1b, 1c. Conclusion: IBD admissions complicated by VTE have significantly increased. Though increasing awareness of VTE with IBD flare may have resulted in additional diagnoses, the study findings suggest that current VTE prophylaxis, or utilization of VTE prophylaxis, may be inadequate for those hospitalized for IBD flare.Figure 1.: VTE rates as % of total IBD hospitalizations per year. Table 1. - Patient Demographics and Hospital Characteristics of IBD Patients Admitted with VTE Variable Crohn's Disease (n=73,530) Ulcerative Colitis (n=58,011) Age in years [Mean(SD)] 56 (0.16) 60 (0.19) Sex Male 43.7% 50.3% Female 56.3% 49.7% Race* White 81.1% 79.6% Black 12.3% 10.4% Hispanic 3.8% 6.1% Asian / Pacific Islander 0.5% 1.1% Native American 0.4% 0.4% Other 1.9% 2.5% Insurance Type Medicare 48.5% 48.9% Medicaid 12.5% 8.8% Private Insurance 32.7% 36.4% Self-Pay 3.2% 2.8% Other 3.1% 3.1% Hospital Bed Size Small 13.8% 13.5% Medium 25.1% 24.8% Large 61.1% 61.7% Hospital Location/ Type Rural 7.2% 6.1% Urban Nonteaching 28.0% 28.9% Urban Teaching 64.8% 65.0% Charlson Comorbidity Index CCI = 0 36.4% 35.5% CCI = 1 21.8% 21.3% CCI = 2 15.5% 14.7% CCI ≥ 3 26.3% 28.6% Hospitalization Cost $95,500 $110,473 Length of Stay (in mean days) 10.39 11.25 Death (per 1,000 hospitalizations) 41.8 61.4 *There were some charts where race was documented in NIS as unknown.

Venous Thromboembolism Prophylaxis in Inflammatory Bowel Disease: A Two-year Retrospective Study of Patients Presenting With Inflammatory Bowel Disease to a Community Hospital.

ObjectiveWe set out to determine the rate of pharmacological venous thromboembolism (VTE) prophylaxis among patients admitted with inflammatory bowel disease (IBD) and indirectly compare it to national trends. We also assessed the demographic and clinical correlates for non-prescription of pharmacologic VTE prophylaxis among IBD patients with and without a flare.MethodsWe extracted data from 123 patients admitted to our facility with IBD from September 2018 to August 2020 retrospectively. Out of this cohort, 26 patients were excluded and 96 were included in our analysis. Baseline characteristics were analyzed using descriptive statistics. Multiple logistic regression was used to evaluate the correlates of pharmacological VTE prophylaxis use in individuals with IBD and to analyze the predictors of VTE prophylaxis use in patients with IBD flares.ResultsOut of the 96 patients with IBD included in this study, 61 (63.5%) presented with an IBD flare, and among those with a flare, 26/61 (42.6%) received VTE prophylaxis. IBD patients aged ≥ 65 years and of Black race were less likely to be placed on pharmacological VTE prophylaxis (adjusted odds ratio (AOR) 0.20, 95% CI (0.06 - 0.70), p-value 0.012) and (AOR 0.16, 95% CI (0.05 - 0.50), p-value 0.002) respectively. Among those with a flare, the presence of bright red bleeding per rectum was associated with a low rate of pharmacologic VTE use (AOR 0.01, 95% CI (0.00 -1.78), p-value 0.001). Overall the rate of VTE prophylaxis use in the IBD patient cohort was 56.3% and this was irrespective of flare status.ConclusionOur study showed the low rate of pharmacologic VTE prophylaxis use in IBD patients at this center and this finding was in line with national trends. Interestingly age and the race of patients played a major role in the decision to provide pharmacological VTE prophylaxis but the reason for this finding was not explored by our study. A larger multi-center study is needed to further evaluate these relationships.

Use of Venous Thromboembolism Prophylaxis in Hospitalized Patients: Knowledge and Practice Among Physicians in Nepal.

IntroductionDespite the importance of Venous Thromboembolism (VTE) prophylaxis in hospitalized patients, audits have shown inadequate use of VTE prophylaxis methods around the world. We aimed to assess knowledge, attitudes, and behaviors regarding VTE prophylaxis among clinicians in Nepal.MethodologyA cross-sectional questionnaire-based survey was conducted using an online survey platform.Results199 (60.7%) of the respondents were aware of the risk factors-based risk stratification approach to VTE prophylaxis in hospitalized patients. Only 154 (47%) of the physicians reported institute-based protocols for VTE prophylaxis.ConclusionWe found a significant lack of awareness on risk factors-based stratification strategy for VTE prevention practices among Nepalese physicians. We recommend educational efforts for Nepalese physicians on the overall impact of VTE on mortality and morbidity of hospitalized patients. Our study highlights the needs for adoption of institution-based protocols for VTE prophylaxis and prevention.

SP11.9 Balancing Risk of Haematoma and Venous Thrombosis in VTE Prophylaxis for Breast Cancer Surgery: A Systematic Review and Meta-Analysis

Abstract Introduction Venous thromboembolism (VTE) is a largely preventable cause of morbidity and mortality in post-operative patients, however Guidelines for VTE prophylaxis in breast cancer surgery are not well-established. Methods A comprehensive search was undertaken of all studies that described the role of VTE prophylaxis in breast cancer surgery. Comparative studies that reported on postoperative outcomes between patients who received VTE prophylaxis (prophylaxis) and those who did not (no prophylaxis) were included in the analysis. A meta-analysis using random-effects model was used to analyze key outcomes, with data presented as odds ratio (OR). Results A total of 2470 patients from 6 studies were included in this study. Of these patient, 60.9% (n: 1504) received prophylaxis. The haematoma rate in this study is 0.05% (n: 133). The incidence of haematoma was significantly associated with the use of prophylaxis (6.85% versus 3.11%, p: 0.001). Surgical intervention for haematomas was also significantly associated in this group (3.15% versus 0.83%, p: 0.004). However there was no difference in VTE events between both groups (0.26% versus 0.36%, p: 0.88). Conclusion The use of VTE prophylaxis in breast cancer surgery is associated with increased haematomas without any benefit in preventing venous thromboembolic events. Further studies that examine the use of risk assessment tools for VTE prophylaxis in high risk patients may be beneficial.

Venous thromboembolism prophylaxis in hospitalized sickle cell disease and sickle cell trait patients

Sickle trait (Hb SA) or sickle disease (Hb SS) carries increased risk of venous thromboembolism (VTE). Hb SS patients are young and lack common comorbid conditions that qualify them for VTE prophylaxis (VTEP). Retrospective, multicenter analysis of Hb SS/Hb SA adult patients between January 2013 and December 2018. There were 803 Hb SA (525 patients) and 1020 Hb SS admissions (262 patients). VTEP use was similar between Hb SA and controls (42% vs. 46%; p-value=.06) and Hb SS and controls (45% vs. 42%; p-value=.13). Hb SS/Hb SA patients more frequently received more than half of prescribed doses of VTEP. In multivariate analysis, increasing age and longer hospitalizations were positive predictors. Odds of VTEP use varied with treatment site for Hb SS patients, whereas comorbid conditions, admission hemoglobin and platelet count were not predictive. By contrast, in Hb SA patients, comorbid conditions, higher admission hemoglobin, and higher admissionplatelet counts raised the odds of VTEP being offered. VTEP is underused in Hb SS/Hb SA patients. There may be a trend toward offering more VTEP in Hb SS disease, but not in Hb SA patients, where VTEP prescribing is driven by comorbid conditions rather than genotype. Patient compliance does not appear to play a major role, but intercenter variability suggests provider education may improve VTEP use.

The American Society for Metabolic and Bariatric Surgery (ASMBS) updated position statement on perioperative venous thromboembolism prophylaxis in bariatric surgery

The following position statement is the second update by the American Society for Metabolic and Bariatric Surgery (ASMBS) on prophylactic measures for reducing the risk of venous thromboembolism (VTE) in bariatric surgery patients, after the previous update in 2013 [ [1] Clinical Issues Committee of the American Society for Metabolic and Bariatric SurgeryASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis. 2013; 9: 493-497 Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar ]. The purpose of this statement is to enhance the quality of care in bariatric surgery by reviewing the available evidence on VTE prophylaxis. Since there is limited high-quality data, these practice guidelines suggest some recommendations that are based on available knowledge, peer-reviewed scientific literature, and expert opinion regarding reasonable use of prophylactic measures for VTE in bariatric surgery patients. The intent of issuing such a statement is to provide objective information regarding the use of VTE prophylaxis and its possible role in the prevention of such complications. The statement will be revised in the future when additional evidence becomes available. VTE prevention in bariatric surgery: from where have we come, and how did we get here?Surgery for Obesity and Related DiseasesVol. 18Issue 2PreviewThe American Society for Metabolic & Bariatric Surgery (ASMBS) Clinical Issues Committee (CIC) has published 3 position statements on the issue of venous thromboembolism (VTE) prevention in bariatric surgery, including the most recent in this issue of the journal [1]. The authors of this accompanying editorial are the 3 previous chairs of the ASMBS CIC who served during the timeframe in which the previous statements were issued. The purpose of this editorial is to add some perspective to publication of the current position statement that updates the ASMBS position. Full-Text PDF

Venous Thromboembolism Prophylaxis and Hormonal Contraceptive Management Practice Patterns in the Perioperative Period for Anterior Cruciate Ligament Reconstruction

PurposeTo evaluate the venous thromboembolism (VTE) prophylaxis practices of surgeons performing anterior cruciate ligament reconstruction (ACLR) in female patients using hormonal contraceptives.MethodsOur research team designed an investigational survey using branching logic that was made available to the AANA membership. The survey was designed to identify clinical decision making regarding VTE prophylaxis after ACLR in patients without risk factors for VTE, the counseling of patients about VTE risk associated with hormonal contraceptives, and the use of VTE prophylaxis after ACLR in patients taking hormonal contraceptives.ResultsNinety-four respondents completed the survey. Eighty-nine respondents identified their gender (63% male and 37% female respondents). Respondents reported performing the following number of ACLRs annually: more than 50 (40%), 30 to 50 (29%), 15 to 30 (29%), and fewer than 15 (2%). Of the respondents, 62 (67%) reported that VTE developed after ACLR in their patients (male patients only, 32%; female patients only, 24%; and both male and female patients, 34%). Sixty-seven percent used chemoprophylaxis after ACLR. Surgeons who asked about hormonal contraceptive use were more likely to be women (P = .01; odds ratio [OR], 4.2). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to be women (P = .02; OR, 2.8). Surgeons who asked about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .03; OR, 2.9). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .001; OR, 4.6).ConclusionsThere is no standard of care for VTE prophylaxis after ACLR. A surgeon’s own gender and prior clinical experience with VTE after ACLR may influence his or her likelihood to consider a patient’s hormonal contraceptive use regarding VTE risk after ACLR.Clinical RelevanceThe use of hormonal contraception is a risk factor for VTE in female patients undergoing ACLR. It is important to identify current practice patterns and the need for a standard of care.