For Venous Thromboembolism, Prophylaxis Falls Short Worldwide

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).

More than half of hospitalized patients worldwide are at risk for venous thromboembolism, and despite the availability of evidence-based guidelines, the rate of appropriate prophylaxis remains low, a new study has found.

With pulmonary embolism accounting for 5%-10% of deaths among hospitalized patients, venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death, investigators reported.

Dr. Alexander T. Cohen of King's College Hospital, London, and his colleagues enrolled 68,183 patients from 358 hospitals in 32 countries into the cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study.

Patients 40 years and older being treated in medical wards and those 18 years and older being treated on general surgical wards were assessed by chart review for risk for VTE according to the 2004 American College of Chest Physicians (ACCP) guidelines.

Among the 37,356 medical patients, 49% were women; the median age was 67 years. Among the 30,827 surgical patients, 48% were women; the median age was 59 years.

The researchers found that 15,487 medical patients (42%) were at risk for VTE, with the most common risk factors present before hospitalization being chronic pulmonary disease and heart failure. They identified 19,842 surgical patients (64%) who were at risk, with obesity being the most common prehospitalization risk factor.

The most common postadmission risk factors among both medical and surgical patients were complete immobilization, immobilization with bathroom privileges, and admission to intensive or critical care units. Overall, 35,329 (52%) were at risk.

Further analysis determined that only half of these at-risk patients (17,732) received ACCP-recommended types of prophylaxis, which include low-dose unfractionated heparin, low-molecular-weight heparin, graduated compression stockings, and/or intermittent pneumatic compression devices. When prophylaxis was given, low-molecular-weight heparin was the agent most often used.

Not only was prophylaxis underused in at-risk patients, but the investigators also found that 34% of surgical patients and 29% of medical patients considered at low risk for VTE were given prophylaxis (Lancet 2008;371:387–94).

Overall, the proportion of hospital patients at risk for VTE ranged from 36% to 73% and the proportion of patients receiving ACCP-recommended prophylaxis ranged from 2% to 84%, the investigators reported.

These differences could reflect factors such as physician awareness, availability of guidelines, and local resources. In the United States, 48% of at-risk medical patients and 71% of at-risk surgical patients received recommended prophylaxis, while in Thailand the corresponding figures were 4% and 0.2%.

They also noted that the use of prophylaxis was particularly low among medical patients, with only 37% of those hospitalized with active malignancy or ischemic stroke—among the highest-risk groups—receiving recommended prophylaxis.

In an editorial, Dr. Walter Ageno and Dr. Francesco Dentali of the University of Insubria, Varese, Italy, noted that local programs such as electronic alerts for clinicians are effective and should be promoted. But before such tools can be effectively implemented, the prevalence of the problem must be more broadly appreciated and disagreements about benefits and risks resolved.

“Different perceptions of the benefit-to-risk ratio of pharmacological prophylaxis exist between ischaemic stroke specialists, and some stroke guidelines do not recommend routine use of pharmacologic prevention strategies.” Guidelines should be more comprehensively endorsed among medical and surgical societies, they wrote (Lancet 2008;371:361–2).