A clinical audit of thrombophilia testing in pediatric patients with acute thromboembolic events: impact on management

Abstract

Key Points• Thrombophilia testing does not affect clinical management in the acute setting after a TEE in children and should be avoided.• Potential harms of thrombophilia testing include unnecessary blood draws in children and an estimated cost of $82 000.Routine testing for inherited and acquired thrombophilia defects is frequently performed in pediatric patients with thromboembolic events (TEEs). No consensus guidelines exist regarding the timing of testing or the type of patients to be tested. The primary objective of our study, therefore, was to determine whether thrombophilia testing during the acute TEE setting affected clinical management in pediatric patients. A secondary aim included estimation of potential harm from thrombophilia testing. We retrospectively reviewed data on all pediatric patients diagnosed with a TEE during a 1-year period. Fifty-two (51%) of 102 patients with a TEE underwent thrombophilia testing during the acute phase, with 26 patients (50%) having a positive test result during the acute phase. Only 12% of patients tested were confirmed to have a thrombophilia eventually, yielding a false-positive rate of ;7% for testing when performed in the acute setting. There were no changes to the acute management, regardless of a positive or negative result. Testing resulted in unnecessary blood loss in 12 patients younger than 1 year and acute testing cost approximately $82 000.Our data show that thrombophilia testing during acute TEEs in pediatric patients did not impact clinical management. There is also a potential for false-positive tests leading to unnecessary long-term anticoagulation. These findings suggest against thrombophilia testing during acute TEE setting in children.

Hypercoagulable workup in a community hospital setting: to test or not to test; that is the question

“…The percentage of patients with inappropriate indications for testing in this study are in agreement with several recent similar studies. Shen et al reporting appropriate indications in 34% of patients, in which appropriate testing was also defined as an unprovoked thrombosis or ≥ 3 pregnancy losses [9]. The authors established local guidelines to prevent testing during the acute thrombotic event or while the patient is on anticoagulation, resulting in an 84% reduction in ordered tests after 22 months and an estimated savings of over $100,000 per month.…”

“…Moreover, testing for thrombophilia is costly, with panels ranging from $1,100 and $2,400, and annual Medicare spending between $300-$672 million in the USA on thrombophilia testing [7,8]. Institutional studies have reported annual costs of $62,000 to over $1 million for thrombophilia testing [9,10]. Shen et al reported that consultation with transfusion medicine service prior to ordering thrombophilia tests saved $104,400 per month and reduced panels ordered by 92% [10].…”

Neonatal Myocardial Infarction: A Proposed Algorithm for Coronary Arterial Thrombus Management

“…In general, thrombophilia testing has not impacted management and results in iatrogenic blood loss and cost. 23 AT activity testing, before initiation of anticoagulation, is most useful to determine whether replacement is indicated to achieve heparin efficacy. However, given the critical timing and potentially fatal outcomes, we recommend empiric administration of AT replacement at time of heparin initiation since neonates are expected to have low levels of AT.…”

Updated recommendations for the treatment of venous thromboembolism

“…The developmental stage of the hemostatic system in children, physiologically lower levels of coagulant and anticoagulant proteins, and other confounding factors, such as concomitant use of drug, infection, or inflammation, should be addressed [ 68 - 70 ]. Generally, the tests for thrombophilia do not change decisions about the initiation and duration of acute management, except for specific patients with purpura fulminans complicating severe protein C or S deficiency or cases with VKA-induced skin necrosis [ 71 - 73 ].…”