Many Patients at Risk Never Receive VTE Prophylaxis

NEW ORLEANS — Nearly two-thirds of 9,675 medical patients at risk for venous thromboembolism received no inpatient pharmacologic prophylaxis and more than 98% received no outpatient prophylaxis, a retrospective analysis showed.

The analysis is unique in that it assessed both inpatient and outpatient pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients at risk of VTE, Dr. Alpesh N. Amin and his associates reported in a poster at the annual meeting of the American Society of Hematology.

“Further efforts to improve VTE prevention in medical patients are required, with particular emphasis needed on the transition to outpatient prophylaxis,” the authors concluded. Most hospitalized medical patients have at least one VTE risk factor, with the risk persisting for several weeks after discharge. In addition to hospitalization for a medical illness, VTE risk factors in the study included age at least 60 years (40.5% of patients), malignancy (28%), and obesity (19%).

Overall, 6,185 patients (64%) did not receive any pharmacologic VTE prophylaxis while hospitalized, reported Dr. Amin, executive director of the hospitalist program and professor and chair of medicine at the University of California at Irvine, and his associates. Lack of thromboprophylaxis was most apparent in patients with cancer, occurring in about 70% of 2,544 patients.

Among the 3,490 patients who received pharmacologic VTE prophylaxis, 2,045 received enoxaparin and 1,044 received unfractionated heparin. Enoxaparin was the most commonly prescribed prophylactic agent in patients with heart failure, severe lung disease, or infectious disease; heparin was the most commonly prescribed agent in patients with cancer.

“Even when pharmacological VTE prophylaxis was provided for the duration of hospitalization, the median length of hospital stay was just 3 days in this study, which falls short of the 6–14 days of VTE prophylaxis provided in clinical trials in medical at-risk patients,” Dr. Amin and his associates wrote.

A total of 2,854 patients (29.5%) first received prophylaxis on the last day or next-to-last day of their hospital stay.

In the 30 days following hospital discharge, 98.2% of the medical patients analyzed received no further pharmacologic VTE prophylaxis. Among the 174 medical discharges who did receive outpatient pharmacologic prophylaxis, most received warfarin alone, followed by enoxaparin plus warfarin. Patients with heart failure had the highest level of outpatient prophylaxis within 30 days after discharge (4.8%), and infectious disease patients had the lowest level (1.1%).

For the study, inpatient data from the Premier's Perspective database were cross-matched at the individual patient level with Ingenix LabRx outpatient data from the i3 database (January 2005–December 2007). Patients at least 40 years old and at risk of VTE according to the 2004 American College of Chest Physicians guidelines were included if they had cancer (without surgery), heart failure, severe lung disease, or infectious disease. The data, which came from hospitals in diverse geographic areas, “may not be representative of the U.S. population as a whole,” the researchers noted.

The study excluded patients with contraindications to pharmacologic VTE prophylaxis and those without health plan eligibility in the 3 months before and the 6 months after hospitalization.

The authors disclosed receiving editorial support from Sanofi-Aventis U.S. in the preparation of the poster, but noted that they were fully responsible for all content and editorial decisions. Coauthor Jay Lin, Ph.D., is an employee of Sanofi-Aventis, and coauthor Amy Ryan is an employee of Premier Inc.

My Take

VTE Prophylaxis Still Inconsistent

Over the last 2 decades, the medical community has repeatedly demonstrated the lack of uniform VTE prophylaxis for medical patients at risk. This analysis is contemporary and suggests that the push for VTE prevention by the National Quality Forum, the Agency for Healthcare Research and Quality, and the Leapfrog Group has not been that successful in changing practice. It will be interesting to see if the new Joint Commission core measures on VTE prevention lead to improvements.

This study also highlights the inadequate duration of VTE prophylaxis. Research shows that 6–14 days of prophylaxis is effective, yet patients today aren't hospitalized long enough to receive treatment of this duration. Achieving better outpatient prophylaxis is a major challenge, and some of the new anticoagulants soon to be available may help in this regard.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

NEW ORLEANS — Nearly two-thirds of 9,675 medical patients at risk for venous thromboembolism received no inpatient pharmacologic prophylaxis and more than 98% received no outpatient prophylaxis, a retrospective analysis showed.

The analysis is unique in that it assessed both inpatient and outpatient pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients at risk of VTE, Dr. Alpesh N. Amin and his associates reported in a poster at the annual meeting of the American Society of Hematology.

“Further efforts to improve VTE prevention in medical patients are required, with particular emphasis needed on the transition to outpatient prophylaxis,” the authors concluded. Most hospitalized medical patients have at least one VTE risk factor, with the risk persisting for several weeks after discharge. In addition to hospitalization for a medical illness, VTE risk factors in the study included age at least 60 years (40.5% of patients), malignancy (28%), and obesity (19%).

Overall, 6,185 patients (64%) did not receive any pharmacologic VTE prophylaxis while hospitalized, reported Dr. Amin, executive director of the hospitalist program and professor and chair of medicine at the University of California at Irvine, and his associates. Lack of thromboprophylaxis was most apparent in patients with cancer, occurring in about 70% of 2,544 patients.

Among the 3,490 patients who received pharmacologic VTE prophylaxis, 2,045 received enoxaparin and 1,044 received unfractionated heparin. Enoxaparin was the most commonly prescribed prophylactic agent in patients with heart failure, severe lung disease, or infectious disease; heparin was the most commonly prescribed agent in patients with cancer.

“Even when pharmacological VTE prophylaxis was provided for the duration of hospitalization, the median length of hospital stay was just 3 days in this study, which falls short of the 6–14 days of VTE prophylaxis provided in clinical trials in medical at-risk patients,” Dr. Amin and his associates wrote.

A total of 2,854 patients (29.5%) first received prophylaxis on the last day or next-to-last day of their hospital stay.

In the 30 days following hospital discharge, 98.2% of the medical patients analyzed received no further pharmacologic VTE prophylaxis. Among the 174 medical discharges who did receive outpatient pharmacologic prophylaxis, most received warfarin alone, followed by enoxaparin plus warfarin. Patients with heart failure had the highest level of outpatient prophylaxis within 30 days after discharge (4.8%), and infectious disease patients had the lowest level (1.1%).

For the study, inpatient data from the Premier's Perspective database were cross-matched at the individual patient level with Ingenix LabRx outpatient data from the i3 database (January 2005–December 2007). Patients at least 40 years old and at risk of VTE according to the 2004 American College of Chest Physicians guidelines were included if they had cancer (without surgery), heart failure, severe lung disease, or infectious disease. The data, which came from hospitals in diverse geographic areas, “may not be representative of the U.S. population as a whole,” the researchers noted.

The study excluded patients with contraindications to pharmacologic VTE prophylaxis and those without health plan eligibility in the 3 months before and the 6 months after hospitalization.

The authors disclosed receiving editorial support from Sanofi-Aventis U.S. in the preparation of the poster, but noted that they were fully responsible for all content and editorial decisions. Coauthor Jay Lin, Ph.D., is an employee of Sanofi-Aventis, and coauthor Amy Ryan is an employee of Premier Inc.

My Take

VTE Prophylaxis Still Inconsistent

Over the last 2 decades, the medical community has repeatedly demonstrated the lack of uniform VTE prophylaxis for medical patients at risk. This analysis is contemporary and suggests that the push for VTE prevention by the National Quality Forum, the Agency for Healthcare Research and Quality, and the Leapfrog Group has not been that successful in changing practice. It will be interesting to see if the new Joint Commission core measures on VTE prevention lead to improvements.

This study also highlights the inadequate duration of VTE prophylaxis. Research shows that 6–14 days of prophylaxis is effective, yet patients today aren't hospitalized long enough to receive treatment of this duration. Achieving better outpatient prophylaxis is a major challenge, and some of the new anticoagulants soon to be available may help in this regard.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

NEW ORLEANS — Nearly two-thirds of 9,675 medical patients at risk for venous thromboembolism received no inpatient pharmacologic prophylaxis and more than 98% received no outpatient prophylaxis, a retrospective analysis showed.

The analysis is unique in that it assessed both inpatient and outpatient pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients at risk of VTE, Dr. Alpesh N. Amin and his associates reported in a poster at the annual meeting of the American Society of Hematology.

“Further efforts to improve VTE prevention in medical patients are required, with particular emphasis needed on the transition to outpatient prophylaxis,” the authors concluded. Most hospitalized medical patients have at least one VTE risk factor, with the risk persisting for several weeks after discharge. In addition to hospitalization for a medical illness, VTE risk factors in the study included age at least 60 years (40.5% of patients), malignancy (28%), and obesity (19%).

Overall, 6,185 patients (64%) did not receive any pharmacologic VTE prophylaxis while hospitalized, reported Dr. Amin, executive director of the hospitalist program and professor and chair of medicine at the University of California at Irvine, and his associates. Lack of thromboprophylaxis was most apparent in patients with cancer, occurring in about 70% of 2,544 patients.

Among the 3,490 patients who received pharmacologic VTE prophylaxis, 2,045 received enoxaparin and 1,044 received unfractionated heparin. Enoxaparin was the most commonly prescribed prophylactic agent in patients with heart failure, severe lung disease, or infectious disease; heparin was the most commonly prescribed agent in patients with cancer.

“Even when pharmacological VTE prophylaxis was provided for the duration of hospitalization, the median length of hospital stay was just 3 days in this study, which falls short of the 6–14 days of VTE prophylaxis provided in clinical trials in medical at-risk patients,” Dr. Amin and his associates wrote.

A total of 2,854 patients (29.5%) first received prophylaxis on the last day or next-to-last day of their hospital stay.

In the 30 days following hospital discharge, 98.2% of the medical patients analyzed received no further pharmacologic VTE prophylaxis. Among the 174 medical discharges who did receive outpatient pharmacologic prophylaxis, most received warfarin alone, followed by enoxaparin plus warfarin. Patients with heart failure had the highest level of outpatient prophylaxis within 30 days after discharge (4.8%), and infectious disease patients had the lowest level (1.1%).

For the study, inpatient data from the Premier's Perspective database were cross-matched at the individual patient level with Ingenix LabRx outpatient data from the i3 database (January 2005–December 2007). Patients at least 40 years old and at risk of VTE according to the 2004 American College of Chest Physicians guidelines were included if they had cancer (without surgery), heart failure, severe lung disease, or infectious disease. The data, which came from hospitals in diverse geographic areas, “may not be representative of the U.S. population as a whole,” the researchers noted.

The study excluded patients with contraindications to pharmacologic VTE prophylaxis and those without health plan eligibility in the 3 months before and the 6 months after hospitalization.

The authors disclosed receiving editorial support from Sanofi-Aventis U.S. in the preparation of the poster, but noted that they were fully responsible for all content and editorial decisions. Coauthor Jay Lin, Ph.D., is an employee of Sanofi-Aventis, and coauthor Amy Ryan is an employee of Premier Inc.

My Take

VTE Prophylaxis Still Inconsistent

Over the last 2 decades, the medical community has repeatedly demonstrated the lack of uniform VTE prophylaxis for medical patients at risk. This analysis is contemporary and suggests that the push for VTE prevention by the National Quality Forum, the Agency for Healthcare Research and Quality, and the Leapfrog Group has not been that successful in changing practice. It will be interesting to see if the new Joint Commission core measures on VTE prevention lead to improvements.

This study also highlights the inadequate duration of VTE prophylaxis. Research shows that 6–14 days of prophylaxis is effective, yet patients today aren't hospitalized long enough to receive treatment of this duration. Achieving better outpatient prophylaxis is a major challenge, and some of the new anticoagulants soon to be available may help in this regard.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.