Proportion of US Hospitalized Medically Ill Patients Who May Qualify for Extended Thromboprophylaxis

Abstract

Extended thromboprophylaxis with oral anticoagulation can reduce the risk of symptomatic venous thromboembolism (VTE) in high-risk patients. We sought to estimate the proportion of medically ill patients in the United States who might qualify for extended thromboprophylaxis according to the criteria used in the Medically-Ill Patient Assessment of Rivaroxaban versus Placebo in Reducing Post-Discharge Venous ThromboEmbolism Risk (MARINER) trial. We analyzed 2014 National Inpatient Sample (NIS) data that provide a 20% weighted annual sample of all discharges from US acute-care hospitals. Hospitalizations for acute medically ill patients were identified as those with a primary discharge diagnosis code for heart or respiratory failure, ischemic stroke, infection, or inflammatory diseases. Patients were excluded if they were <40 years old, admitted for surgery or trauma, had a length of stay <3-or >35-days, or were contraindicated to nonvitamin K antagonist oral anticoagulants. The modified International Medical Prevention Registry on Venous Thromboembolism (IMPROVE)-VTE score was used to stratify patients' risk for postdischarge VTE, with a score of 2 to 3 suggesting patients were at moderate-and 4 as high-risk. Of the 35 358 810 hospitalizations in the 2014 NIS, 1 849 535 were medically ill patients admitted for heart failure (10.1%), respiratory failure (12.2%), ischemic stroke (8.8%), infection (58.5%), or inflammatory diseases (10.4%). The modified IMPROVE-VTE score classified 1 186 475 (64.1%) of these hospitalizations as occurring in moderate-risk and 407 095 (22.0%) in high-risk patients. This real-world study suggests a substantial proportion of acute medically ill patients might benefit from extended thromboprophylaxis using the modified IMPROVE-VTE score and clinical elements of the MARINER trial.

Modified IMPROVE VTE Risk Score and Elevated D-Dimer Identify a High Venous Thromboembolism Risk in Acutely Ill Medical Population for Extended Thromboprophylaxis

“…Thus, our results would further define $60% of an at-VTE risk population of medically ill patents that would benefit from both in-hospital and ET, or $25 to 30% of the total population of medically ill patients. 1,2 The modified IMPROVE VTE risk score plus elevated D-dimer used in our study has the potential to be incorporated as a clinical decision support tool within a health system's electronic health records both at admission and at discharge, where previous efforts in hospitalized medical patients have shown an increase in uptake of appropriate thromboprophylaxis as well as a decrease in VTE using electronic or physician alerts at admission and discharge. 21,22 Limitations of the present analysis include its retrospective design in a subpopulation of the original MAGELLAN study population, which can introduce recall bias.…”

“…1 It is estimated that approximately one-quarter of hospitalized medically ill patients are at high VTE risk. 1,2 Data from randomized controlled trials of ET with the direct oral anticoagulants (DOACs) betrixaban and rivaroxaban reveal net clinical benefit of such a strategy in key patient groups or subgroups, and these agents have gained regulatory approval in the US. 3,4 However, identification of such patients using a standardized approach remains difficult.…”

Factors Influencing Prescribers' Decision for Extending Venous Thromboembolism Prophylaxis in the Medical Patient Population following Hospitalization

“…3 Previous clinical trials have assessed the validity of prolonging VTE prophylaxis posthospital discharge and compared current available therapeutic agents for efficacy. [4][5][6][7] As hospitalization is the highest ranked risk factor for the development of VTE, use of VTE prophylaxis for acutely ill medical patients has become a standard of care. 8 Standard prophylaxis is given during hospitalization based on certain risk characteristics, such as a current diagnosis of pneumonia, acute respiratory failure, heart failure, or history of stroke among other criteria associated with increased VTE risk in the acute medically ill population.…”

“…Current data show both apixaban and rivaroxaban are noninferior to traditional enoxaparin for short durations (10-14 days) postdischarge but notably showed no benefit for a prolonged duration (30-35 days) and increased the incidence of bleeding. [4][5][6][7] An additional clinical trial looked at the efficacy of a new comer, betrixaban, for reducing the risk of VTE postdischarge in a subset of patients considered to be at high risk for VTE prophylaxis. 15 Investigators found benefit in patients with elevated D-dimer or aged over 75 years and in the younger patients with specific risk factors such as a history of VTE or a history of cancer.…”

“…15 Investigators found benefit in patients with elevated D-dimer or aged over 75 years and in the younger patients with specific risk factors such as a history of VTE or a history of cancer. 7,15,16 Currently, at our hospital, VTE prophylaxis is required for all patients at intermediate or high risk for VTE during the hospitalization. All admission order sets have prompts to encourage either the ordering of VTE prophylaxis or a reason that VTE prophylaxis is not needed.…”