Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism (original) (raw)
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JAMA internal medicine, 2014
IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients.
American Journal of Therapeutics, 2016
Patients hospitalized with acute medical illness have an elevated risk of venous thromboembolism (VTE). American College of Chest Physicians guidelines list various chronic illnesses, sepsis, advanced age, history of VTE, and immobility as risk factors and recommend prophylactic anticoagulation using fondaparinux, low-molecular weight heparin, or low-dose unfractionated heparin. The objectives of this study were to examine pharmacological prophylaxis against VTE among hospitalized medically ill patients and to assess demographic and clinical correlates related to VTE prophylaxis. A retrospective (1999-2010) electronic medical records study included patients aged 40 years and older hospitalized for at least 3 days, with significant medical illness or with a VTE hospitalization 30-365 days before admission. Each patient's first qualifying hospitalization was analyzed. Exclusions were if VTE treatment was started within 1 day of admission, or if warfarin (and not heparin or enoxaparin) was used. Prophylaxis was defined if the first inpatient dose of subcutaneous heparin or enoxaparin was at prophylaxis levels (lower than treatment levels). Multivariable logistic regression was used to examine factors associated with VTE prophylaxis. Among 12,980 patients, 22.1% received prophylaxis (11.8% with enoxaparin, 10.3% with heparin). VTE prophylaxis was positively associated with year of hospitalization, subcutaneous heparin in the month before admission, aspirin, self-pay status, age, and sepsis. VTE prophylaxis was negatively associated with smoking, alcohol, warfarin in the past 30 days, and primary diagnoses of stroke, infectious disease, or inflammatory bowel disease. Pharmacological VTE prophylaxis has increased significantly over the past 12 years but is still largely underused in patients hospitalized with acute medical illness. Multiple demographic, behavioral, and clinical factors are associated with inpatient VTE prophylaxis.
2019
TO THE EDITOR: We read with interest the new clinical practice guidelines for venous thromboembolism (VTE) made available on 27 November 2018.1 The evidence-based guidelines from the American Society of Hematology (ASH) highlight the risk of VTE in a variety of settings and provide recommendations for prophylaxis, diagnosis, and optimal management of anticoagulation therapy. Thank you for taking on this important work. However, we feel that the widespread problem of nonadministered doses of prescribed VTE prophylaxis to hospitalized patients is unappreciated in the current guidelines. Despite recognition of the risk of VTE, it remains a significant health care problem. Although continuous efforts are being made to improve VTE prophylaxis presciption,2 these efforts are based on the implied assumption that appropriate VTE prophylaxis prescription guarantees its administration. Nonadministration of VTE prophylaxis can lead to preventable harm,3,4 and regrettably, it is endemic within hospitals. At our institution, we found that ∼12% of prescribed doses of pharmacologic VTE prophylaxis were not administered to hospitalized patients. The most noteworthy finding of our investigation was that nearly 60% of nonadministered doses were due to patient or family member refusal.5 Similarly, researchers at another major academic medical center reported that adherence to unfractionated heparin (UFH) and low-molecular-weight heparin for VTE prophylaxis in hospitalized patients was 87% and 95%, respectively; for both, patient refusal (44%) was the most common reason for missed doses.6 Several factors may have contributed to the observed differences in the nonadministration of UFH and low-molecular-weight heparin. Providers’ perception of patients’ risk might be driven by the patient population or the medication dose frequency, potentially influencing administration. For instance, it has been described that twice daily heparin was missed more frequently than thrice daily heparin. However, twice daily heparin is more frequently prescribed for more medically ill patients.5 Recently, we found that nonadministration is common and perhaps more prevalent at community hospitals compared with academic medical centers.7 These findings suggest that nonadministration of VTE prophylaxis is a ubiquitous deficit in patient care.8 Although some may suggest that these missed doses are inevitable, we would strongly disagree, as evidence suggests that missed doses may be the next salient target to improve care and VTE prevention.9⇓-11 In an attempt to reduce missed doses of VTE, the Johns Hopkins Medicine VTE Collaborative, with funding from the Patient Centered Outcomes Research Institute (PCORI), developed and implemented 2 complementary approaches. The first was a Web-based education module for bedside nurses that decreased missed doses significantly.12 The second was a patient education bundle. The bundle was tested in a controlled pre-post clinical trial to assess the effectiveness of this patient education bundle on VTE prophylaxis and medication administration practices for hospitalized patients. Implementation of the bundle was associated with a 43% reduction in missed doses of VTE prophylaxis and a 47% reduction in patient refusal of prescribed VTE prophylaxis medication.13 Successful strategies to reduce VTE prophylaxis nonadministration have been tested at several other institutions.9⇓-11 In addition, patient surveys and cohort studies suggest that the availability of an oral agent for VTE prophylaxis would significantly reduce nonadministration.14⇓-16 Although patient preferences are important, published literature to help guideline committees is often lacking. However, in this case, data do exist. The majority of patients if presented with an option would choose an oral agent. However, there are a substantial amount of patients who would choose an injectable agent.14 We are in full agreement with ASH that it is important to assess risk and prescribe risk-appropriate VTE prophylaxis. However, we believe that it is critically important to focus on all phases of care for VTE prevention. Although we understand the limitations of time and energy available for a complete systematic review and meta-analysis review of this topic, perhaps a mention of the concept in the discussion would have been appropriate. Even the best evidence-based regimen prescribed would be ineffective if it is not actually administered. Future work to study oral agents for prevention may be warranted as subcutaneous injections for VTE prophylaxis seem to be missed more than other medications,16,17 and many patients would prefer an oral option.15 There are still instances though when UFH and LWMH would be more suitable for prophylaxis (eg, patients with a status of nothing by mouth or some critically ill patients). We have advocated for outcome measures that link a process measure failure and a negative outcome, in particular, in VTE.18 This approach has led to a publicly reported measure of potentially preventable VTE (VTE-6). Perhaps it is time to change this measure to include missed doses alongside prescription failures to define poor quality care.8 We strongly feel that the evidence suggests monitoring missed doses of prescribed VTE prophylaxis within hospitals to further reduce potentially preventable harm from VTE.
Venous thromboembolism prophylaxis in medical inpatients: a retrospective chart review
Thrombosis Research, 2003
Background: Venous thromboembolic disease (VTE) is a major cause of morbidity and mortality in hospitalized patients. Most hospitalized patients with a fatal pulmonary embolism are medical patients who do not have a history of recent surgery [BMJ 302 (1991) 709; J. R. Soc. Med. 82 (1989) 198]. There is evidence suggesting that VTE prophylaxis is indicated in many high risk medical patients [Chest 119 (2001) 132S; NEJM 341 (1999) 793]. However, previous studies have shown that only about one third of high risk medical patients receive VTE prophylaxis [Ann. Intern. Med. 115 (1991) 591; Chest 106 (1994) 13; Chest 107 (1995) 296]. The objective of this study was to determine the frequency of use of VTE prophylaxis in medical inpatients at two teaching hospitals in Hamilton, Ontario. Methods: A retrospective chart review of consecutive patients admitted to medical wards at two acute care sites of McMaster University affiliated teaching hospitals between October 10, 2001 and December 11, 2001 was performed. For each patient, demographic data, risk factors for VTE, method of VTE prophylaxis and contraindications to VTE prophylaxis were recorded. Results: 756 patient charts were reviewed and 310 (41%) were excluded because the primary diagnosis required anticoagulation, the patients were being treated with anticoagulation (warfarin or heparin) before admission or the patient was admitted to the intensive care unit. Of the remaining 446 patients, 146 (33%) received some form of VTE prophylaxis. Of the patients receiving prophylaxis, 4% had early ambulation, 9% wore anti-embolic stockings (AES), 1% used intermittent pneumatic compression, 23% used unfractionated heparin and 3% used low molecular weight heparin. Two hundred five (46%) patients had one identifiable VTE risk factor and 63 (14%) had two or more risk factors. Patients with more VTE risk factors were more likely to receive prophylaxis. Interpretation: One third of medical inpatients at two teaching hospitals in Hamilton received some form of VTE prophylaxis.
Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey)
Annals of Surgery, 2010
Abstract Objective: To evaluate venous thromboembolism (VTE) risk in patients who underwent a major operation, including the use of, and factors influencing, American College of Chest Physicians-recommended types of VTE prophylaxis. Summary background data: The Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) survey, conducted in 358 hospitals in 32 countries, reported that globally, more than 40% of at-risk patients do not receive VTE prophylaxis. Limited data are available regarding VTE prophylaxis practices according to surgery type and patient characteristics. Methods: Patients aged ≥18 years undergoing major surgery were included in this prespecified subanalysis. VTE risk and use of prophylaxis were determined from hospital medical records according to the 2004 American College of Chest Physicians guidelines. Multivariable analyses were performed to identify factors associated with VTE prophylaxis use. Results: Of the 18,461 patients in ENDORSE who had undergone major surgery, 17,084 (92.5%) were at-risk for VTE and 10,638 (62.3%) received prophylaxis. Use of prophylaxis varied according to major surgery type from 86.0% for orthopedic surgery to 53.8% in urologic/gynecologic and 53.6% in other procedures. Major orthopedic surgery was most strongly associated with prophylaxis use (hip replacement: odds ratio 6.2, 95% confidence interval [CI] 5.0-7.6; knee replacement: odds ratio 5.9, 95% CI 4.6-7.8).
Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients *
CHEST Journal, 2007
Background: Evidence-based guidelines recommend that acutely ill hospitalized medical patients who are at risk of venous thromboembolism (VTE) should receive prophylaxis. Our aim was to characterize the clinical practices for VTE prophylaxis in acutely ill hospitalized medical patients enrolled in the International Medical Prevention Registry on Venous Thromboembolism (IM-PROVE). Methods: IMPROVE is an ongoing, multinational, observational study. Participating hospitals enroll the first 10 consecutive eligible acutely ill medical patients each month. Patient management is determined by the treating physicians. An analysis of data on VTE prophylaxis practices is presented. Results: From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the United States and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively). Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with lowmolecular-weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively). Conclusions: Our data suggest that physicians' practices for providing VTE prophylaxis to acutely ill hospitalized medical patients are suboptimal and highlight the need for improved implementation of existing evidence-based guidelines in hospitals. (CHEST 2007; 132:936 -945)
Journal of Thrombosis and Haemostasis, 2008
Background: We investigated clinical predictors of appropriate prophylaxis prior to the onset of venous thromboembolism (VTE). Methods: In 14 Swiss hospitals, 567 consecutive patients (306 medical, 261 surgical) with acute VTE and hospitalization < 30 days prior to the VTE event were enrolled. Results: Prophylaxis was used in 329 (58%) patients within 30 days 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 [odds ratio (OR) 3.28, 95% confidence interval (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 deep vein thrombosis (OR 1.71, 95% CI 1.31-2.24) and prior pulmonary embolism (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, almost half did not receive any form of prophylaxis. Future efforts should focus on the improvement of prophylaxis for hospitalized patients, particularly in patients with cancer, acute heart or respiratory failure, and in the elderly.
The Canadian Journal of Hospital Pharmacy
Background: Venous thromboembolism (VTE) is the most preventable hospital-associated complication, and implementation of appropriate VTE prophylaxis is a requirement for institutional accreditation. However, ambiguity and controversy exist within current recommendations, and greater clarity about and understanding of current utilization of VTE prophylaxis may be needed. Objectives: The primary objective was to assess the proportion of patients receiving appropriate VTE prophylaxis (right drug, dose, frequency, and duration) within 24 h after admission to general internal medicine units. The secondary objectives were to determine the proportion of at-risk patients who experienced adverse events (major bleeding or thrombotic events) in relation to appropriateness of prophylaxis, to describe reasons why VTE prophylaxis was inappropriate, and to compare these findings with local audit data. Methods: This cross-sectional study involved adult patients at moderate to very high risk of VTE who were discharged from general internal medicine units between January 1 and September 30, 2015, at the University of Alberta Hospital in Edmonton, Alberta. Patients with length of stay less than 72 h, those already receiving therapeutic anticoagulation, and those lacking documentation of renal function or weight were excluded. A paired t test was used to compare the study data with audit results. Results: Of 225 patients identified as being at risk of VTE, 179 (79.6%) received appropriate prophylaxis. The most common reasons why VTE prophylaxis was deemed inappropriate were not providing a mechanical method of prophylaxis for patients with bleeding contraindications (18/46 [39.1%]) and incorrect dose of pharmacologic prophylaxis (15/46 [32.6%]). The rate of appropriate VTE prophylaxis was lower than that reported in local audits (79.6% versus 97.6%; p = 0.002). Adverse events were less frequent among those receiving appropriate VTE prophylaxis than among those receiving inappropriate prophylaxis: 1.7% (3/179) versus 6.5% (3/46) for thrombotic events and 4.5% (8/179) versus 19.6% (9/46) for major bleeding. Conclusions: These results provide insight into current prescribing patterns for VTE prophylaxis and highlight the need for continued engagement of the health care team in the provision of appropriate VTE prophylaxis.