Many At-Risk Patients Lack VTE Prophylaxis

BY PATRICE WENDLING
Elsevier Global Medical News

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 risk factor for VTE, with the risk persisting for several weeks following 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 did receive pharmacologic VTE prophylaxis, 2,045 received enoxaparin and 1,044 received unfractionated heparin. Enoxaparin was the most commonly prescribed of the prophylactic agents 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%).

In order to assess pharmacologic VTE prophylaxis, inpatient data from the Premier’s Perspective database were crossmatched 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 various payers and types of hospitals in diverse geographical areas, “may not be representative of the U.S. population as a whole,” the researchers noted.

The analysis did not include patients undergoing orthopedic surgery, and excluded patients with contraindications to pharmacologic VTE prophylaxis and those without health plan eligibility in the 3 months before hospital admission and 6 months following discharge. The mean age of the patients was 58 years; 67% had managed care, 22% Medicare, 8.8% commercial insurance, and 1.3% Medicaid.

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. Coauthors Jay Lin, Ph.D., is an employee of Sanofi-Aventis and Amy Ryan is an employee of Premier Inc.

Dr. Jeana O’Brien, FCCP, comments:
This study by Amin, et al. reports on 9,675 patients who met criteria for venous thromboembolism (VTE) prophylaxis and yet did not receive the indicated therapy. The nature of this retrospective review did not allow a thorough assessment of the reasons this occurred. Unfortunately, prior studies have also demonstrated similar gaps between recommendations and practice. While reasons for this are likely complex and varied, this challenge will most certainly require more than additional education. Evidence-based, standardized order sets and computerized physician order entry are systematic approaches that can prompt the clinician in these settings. As CMS encourages hospitals and physicians to move in this direction through the Meaningful Use proposals of the ARRA, we hopefully will see improvements with future analyses.