Venous thromboembolism in hospitalized patients: An updated analysis of missed opportunities for thromboprophylaxis at a university-affiliated tertiary care center

Abstract

Thromboprophylaxis remains often underused in hospitalized patients. In 2001, a cohort study done at our institution, a tertiary care center in Montreal, Canada, showed that 67.7% of VTE cases necessitating thromboprophylaxis were potentially preventable with adequate use of American College of Chest Physicians (ACCP) guidelines. Following implementation of an institution-wide policy in 2005, we assessed the changes in the rate of potentially preventable VTE. We conducted a retrospective cohort study including all hospitalized patients with objectively diagnosed VTE in 2010 at our institution. Each case was classified as preventable (thromboprophylaxis indicated but inadequately administered), non-preventable (thromboprophylaxis indicated and correctly administered), spontaneous (thromboprophylaxis not indicated), and ineligible (contraindication to thromboprophylaxis). The results were compared to those obtained in 2001. Of the 230 cases of VTE, 55 cases were classified as potentially preventable (23.9%), 85 were non-preventable (37.0%), 74 were spontaneous (32.2%) and 16 (7.0%) were ineligible. Of the 140 cases requiring thromboprophylaxis, 39.3% were potentially preventable. The potentially preventable cases were mostly due to omission of thromboprophylaxis (50.9%), occurred during general medical admissions (74.5%), and the most common VTE risk factor was cancer (47.2%).In conclusion, we demonstrate a lower frequency of potentially preventable cases in 2010 compared to 2001 (39.3% vs 67.7%, respectively), partially due to physician education and adoption of an institution-wide policy. However, patients with medical indications for thromboprophylaxis, particularly those with cancer, are more prone to having preventable VTE, indicating an area for potential improvement.

Unmet definitions in thromboprophylaxis for hospitalized medical patients: An appraisal for the need of recommendation

“…Adequacy of thromboprophylaxis has also been proposed by some studies, although with different criteria. 16 , 17 , 18 , 19 Some authors 17 , 18 , 19 have followed the definitions of the ACCP guideline, while two of them 17 , 18 refined the criteria. For those, thromboprophylaxis was considered as adequate if all the following conditions were fulfilled: (i) The prophylactic agent was prescribed as recommended by the ACCP guideline, by using the same type, dose, and frequency of administration; (ii) thromboprophylaxis was regularly prescribed for at least 7 days, until full mobility or hospital discharge, whichever came first; and (iii) prophylaxis was initiated within 24 h of hospital admission.…”

“…For those, thromboprophylaxis was considered as adequate if all the following conditions were fulfilled: (i) The prophylactic agent was prescribed as recommended by the ACCP guideline, by using the same type, dose, and frequency of administration; (ii) thromboprophylaxis was regularly prescribed for at least 7 days, until full mobility or hospital discharge, whichever came first; and (iii) prophylaxis was initiated within 24 h of hospital admission. 17 , 18 …”

Science of health care delivery

“…These include concerns regarding the risk of bleeding, economic burden, and unfamiliarity, or non-endorsement of published guidelines. 10 As found by Ma and colleagues, 8 one of the primary reasons for low compliance with VTE prophylaxis appears to be omission. With the pressures of a busy practice and the growing trend of hospitalization of only the most complicated and sickest patients, it is easy to understand overlooking VTE prophylaxis.…”

“…In the current issue of Vascular Medicine, Ma and colleagues address the science of health care delivery of appropriate VTE prophylaxis in patients hospitalized at a university-affiliated Montreal hospital. 8 After documenting a high rate of preventable venous thrombotic events at their institution, this group implemented an institution-wide policy to improve thromboprophylaxis implementation. 9 This policy included education, pocket card distribution to members of the health care team, and preprinted admission order sets for surgical patients to encourage proper VTE prophylaxis use.…”

Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries

“… 47 Other studies, including those from HICs, have cited lack of awareness of both the disease and evidence-based guidelines. 48 , 49 Many practitioners seem to believe that VTE is an uncommon diagnosis (based on their own clinical experiences) and therefore VTE prevention may not be considered necessary. 50 This thinking is contrary to findings from several studies demonstrating that Asians have significant risk factors for and increasing incidence of VTE.…”