Outpatient management of patients presenting with venous thromboembolism: Retrospective cohort study at 11 community hospitals

Abstract

A gap exists between clinical practice guidelines and real-world practice. We aim to investigate hospital admissions among patients presenting to emergency departments of 11 hospitals with venous thromboembolism (VTE). Eligible patients’ first emergency department VTE visit were retrospectively collected between 2013 and 2018 from electronic medical records (EMR). Patients were categorized at low risk of VTE complications if they were diagnosed with deep vein thrombosis (DVT) of the leg or if they were diagnosed with pulmonary embolism (PE) and had a PE score index < 85. Multivariable logistic regression models were constructed to measure the adjusted odds ratios (OR) and 95% confidence intervals (CI) of hospital admissions before and after clinical practice guidelines were updated to recommend outpatient management of DVT and PE with low risk of complications. A total of 13,677 patients were included in the analysis, of which 55% were diagnosed with DVT. Mean age was 65 ± 17 years, 54% were females, and 62% were Caucasian. Overall, 9281 patients were categorized at low risk VTE complications, of whom 77% were admitted for in-hospital management. The rate of in-hospital management declined from 81% in 2013 to 73% in 2018. Patients visiting emergency departments between 2016 and 2018 (post-guidelines) were equally likely to be admitted compared to patients visiting the emergency departments between 2013 and 2015 (pre-guidelines; OR = 0.99; 95% CI: 0.88, 1.11). Results from this real-world study indicate that most low-risk VTE patients are admitted for in-hospital management, despite recommendations in clinical practice guidelines.

Guideline Adherence As An Indicator of the Extent of Antithrombotic Overuse and Underuse: A Systematic Review

“…Median underuse in perioperative bridging across the five studies was 25.0% (IQR 13.1 – 32.0%). While no time trend was visually apparent, underuse estimates from five retrospective chart reviews [ 22 25 26 30 32 ] and four cohort studies [ 34 36 38 39 ] since 2020 in Europe and North America have remained below 33% (9–32%) by comparison with 36%–72% reported between 2015 and 2019, but we did not formally test this.…”

“…Study designs included 14 retrospective record reviews [ 20 21 22 23 24 25 26 27 28 29 30 31 32 33 ], 6 cohort studies [ 34 35 36 37 38 39 ] and 1 a case-control [ 40 ] (see Table 1 ). Four studies focused on overuse, 5on underuse, and 12 on both.…”

“…Large variation in the rates of antithrombotic overuse was observed across geographic regions with studies from Asia reporting the lowest levels of overuse (1.3–7.6%) [ 27 33 ], followed by Australia (24.1–42.9%) [ 20 23 24 ], and Europe (1.4–72.0%) [ 21 25 28 29 30 33 36 37 38 39 40 ], through to the highest variation in North America (6.6–73.0%) [ 26 31 32 34 35 ]. No clear time trend of increasing or decreasing overuse was observed over the period of the studies (2008–2020).…”

“…There was a wide range in overuse in venous thromboembolism (VTE) treatment in hospitals, from 7.6% in a study in Iran [ 27 ] to 73% in a US study of patients admitted for VTE treatment contrary to guideline recommendation to manage them as ambulatory patients [ 26 ].…”

“…Patient comorbidities, lack of social support or insurance status as incentive for in-hospital management [ 26 ]…”