Estimation of Acutely Ill Medical Patients at Venous Thromboembolism Risk Eligible for Extended Thromboprophylaxis Using APEX Criteria in US Hospitals

Abstract

Major medical illnesses place patients at risk of venous thromboembolism (VTE). Some risk factors including age ≥75 years or history of cancer place them at increased risk of VTE that extends for at least 5 to 6 weeks following hospital admission. Betrixaban thromboprophylaxis is now approved in the United States for this indication. We estimated the annual number of acutely ill medical patients at extended risk of VTE discharged from US hospital. Major medical illnesses (stroke, respiratory failure/chronic obstructive pulmonary disease, heart failure, pneumonia, other infections, and rheumatologic disorders) and 2 common risk factors for extended VTE risk, namely, age ≥75 years and history of cancer (active or past) were examined in 2014 US hospital discharges using the first 3 discharge diagnosis codes in the National Inpatient Sample (database of acute-care hospital discharges from the US Agency for Health Care Quality and Research). In 2014, there were 20.8 million discharges with potentially at risk of nonsurgical-related VTE. Overall, 7.2 million (35%) discharges corresponded to major medical illness that warranted thromboprophylaxis according to 2012 American College of Chest Physicians (ACCP) guideline. Among them, 2.79 million were aged ≥75 years and 1.36 million had a history of cancer (aged 40-74 years). Overall, 3.48 million discharges were at extended risk of VTE. Many medical inpatients at risk of VTE according to 2012 ACCP guideline might benefit from the awareness of continuing risk and some of these patients might benefit from extended thromboprophylaxis, depending on the risk of bleeding and comorbidities.

Prevention of Venous Thromboembolism in Hospitalized Medically Ill Patients: A U.S. Perspective

“…21,61,67 This has major populational health implications in U.S. health systems, where estimates suggest that approximately 25 to 40% of the 7.2 million medically ill patients are at sufficient VTE risk to benefit from extended thromboprophylaxis. 2,18 Lastly, health informatics technology is evolving. The capability exists to incorporate validated clinical prediction rules such as VTE RAMs into a hospital-based clinician's workflow within an EHR applications based on newer informatics technologies such as "SMART on FHIR."…”

“…75 years, a Past history of cancer or VTE, and EXtra risk factors (comorbidities that are risk factors for VTE) has also been proposed. 18 Recently, a novel biomarker, an elevated D-dimer (Dd) ! 2 Â upper limit of normal has also shown promise in identifying high VTE risk in medically ill populations.…”

“…Approximately 25 to 40% of U.S. medically ill patients are at sufficient VTE risk to benefit from extended thromboprophylaxis. 2,18 Although the initial randomized placebo-controlled trials with the LMWH enoxaparin and direct oral anticoagulants (DOACs) rivaroxaban and apixaban failed to establish a definitive net clinical benefit in support of those agents, more recent evidence from a large randomized trial with the DOAC betrixaban in high VTE risk groups as well as safety and net clinical benefit of rivaroxaban in a recent large randomized trial and in a large patient subgroup of an earlier randomized trial that excluded key bleeding risk factors have led to regulatory approval of both betrixaban and rivaroxaban for extended thromboprophylaxis in medically ill patients. [19][20][21] In contrast, antithrombotic guidelines have recommended an individualized approach to extended thromboprophylaxis or recommended against routine use of extended thromboprophylaxis with DOACs in medically ill patients.…”

Prevention of Venous Thromboembolism in Acutely Ill Medical Patients: A New Era

“…Approximately 25 to 40% of the 7.2 million medically ill patients in the United States may benefit from extended thromboprophylaxis. 3,44 Evidence shows that applying reductions in symptomatic VTE seen in the APEX trial in the United States and European Union would result in $20,000 fewer symptomatic VTEs and the potential to result in 12,000 fewer VTE-related deaths. 45 Patient adherence to extended thromboprophylaxis may be improved by the advent of oral options for medically ill patients for both the in-hospital and extended post-hospital discharge period, and represents an important advancement in the field of thrombosis.…”

New Paradigms of Extended Thromboprophylaxis in Medically Ill Patients

“…Extended thromboprophylaxis in medically ill patients represents a new paradigm for health care professionals as well. Evidence suggests that approximately 25% (and up to 40%) of the 7.2 million medically ill patients in the USA would benefit from extended thromboprophylaxis [42,43]. Applying reductions in symptomatic VTE seen in the APEX trial with betrixaban would result in ~20,000 fewer symptomatic VTEs and the potential to result in 12,000 fewer VTE-related deaths [44].…”