Hospital Thromboprophylaxis Rates a 'Significant Concern'

By Bruce Jancin

SALT LAKE CITY -- Only one-third of U.S. medical inpatients at increased risk for venous thromboembolism receive appropriate prophylaxis as recommended by American College of Chest Physicians guidelines, according to a large study.

About half of the remaining two-thirds of at-risk patients receive suboptimal venous thromboembolism (VTE) prophylaxis. The other half receives none at all, Dr. Alpesh Amin said at the annual meeting of the ACCP.

He reported on 196,104 medical patients at 227 U.S. hospitals participating in the Premier's Perspective national inpatient administrative database in January 2002 through September 2005.

All of the nearly 200,000 patients were at least 40 years old, were hospitalized for a minimum of 6 days, possessed at least one risk factor for VTE, and were without contraindications to anticoagulation. The most common admitting diagnosis was severe lung disease, followed by heart failure, cancer, and acute myocardial infarction.

The appropriateness of thromboprophylaxis was determined by comparing daily use of mechanical compression devices and/or anticoagulants with what was recommended for patients in a given risk category in the ACCP guidelines. To be deemed appropriate, preventive therapy had to be in accord with the recommendations in terms of prophylaxis type and duration as well as daily dosage.

Nearly 62% of patients received some form of VTE prophylaxis. However, only 33.9% received appropriate prophylaxis in keeping with ACCP guidelines, which since the mid-1980s have been the acknowledged standard, according to Dr. Amin, professor and vice chair of medicine and head of the hospitalist program at the University of California, Irvine.

The highest rate of appropriate VTE prophylaxis--49%--occurred in the nearly 9,000 patients hospitalized for ischemic stroke. Among MI patients, 43% received appropriate prophylaxis, as did 40% with heart failure, 31% with lung disease, and 27% with cancer.

VTE is an increasingly high-visibility issue in recent years. It has been estimated to cause 300,000 deaths per year--about the same as acute MI, and more than breast cancer, HIV, liver disease, and accidents combined. An effort is underway to incorporate VTE prophylaxis rates into core hospital quality performance measures starting in 2008. March is now national Deep Venous Thrombosis Awareness Month. Airlines make an effort to educate passengers about the problem on long international flights.

To see if this increased public attention to VTE has been accompanied by a temporal trend for improved rates of appropriate prophylaxis, the investigators analyzed nearly 3 years of data quarterly. They found the rate increased over time, but only modestly, from nearly 30% in early 2002 to 40% in late 2005.

They also analyzed the data by geography, payment type, bed size, rural versus urban hospitals, teaching versus nonteaching hospitals, and whether patients were admitted through the emergency department or by a referring physician.

"Only about one-third got appropriate prophylaxis no matter how you broke it down. We couldn't find one area where we were doing a wonderful job in terms of prophylaxis. There's more to do," he said.

When asked to comment on this article, Dr. Thomas Wakefield, S. Martin Lindenauer Professor of Surgery and section head, vascular surgery at the University of Michigan Ann Arbor, stated: "As the authors point out, the low rate of adherence to appropriate DVT prophylaxis is a real concern. The importance of venous thrombosis as a national health problem has been recognized by the office of the Surgeon General in conjunction with the NIH, and a call to action against venous thrombosis was approved by the Surgeon General in May 2006.

"A formal announcement is expected in early 2007. This effort, along with DVT prophylaxis becoming incorporated into core hospital quality performance measures, should increase the appropriate use of DVT prophylaxis. Vascular specialists are in the perfect position to help lead these efforts."