This article is more than 5 years old. Information may no longer be current.
Number of hospitalized patients at risk for VTE not receiving recommended prophylaxis
Click Here to Manage Email Alerts
Despite the large number of hospitalized patients at risk for venous thromboembolism, appropriate prophylaxis is lacking, according to the results of the ENDORSE trial.
Researchers from the University of Massachusetts in Worcester, along with other institutions, evaluated 68,183 patients in 358 hospitals across 32 countries in order to determine their risk for venous thromboembolism.
Participants were categorized according to type of stay, whether medical (n=37,356, 55%) or surgical (n=30,827, 45%). The medical cohort consisted of patients aged 40 years and older, and the surgical consisted of those aged 18 years and older.
Researchers used the American College of Chest Physicians’ guidelines and found 35,329 patients at risk for venous thromboembolism, including 19,842 surgical patients and 15,487 medical patients. Despite the large number of patients at risk, only 58.5% of surgical patients at risk and 39.5% of medical patients at risk received recommended prophylaxis. – by Stacey L. Adams
Lancet. 2008;371:387-394.
This study highlights a general problem: prophylaxis against venous thromboembolism is underused in hospitalized patients. It is particularly disturbing to me as a hematologist and oncologist that the worst offenders are the medical people and not the surgical people, making this problem particularly bad in medical patients. So, in general, there is an underuse of anti-coagulant prophylaxis, particularly in hospitalized medical patients at risk for venous thromboembolic disease, and I think that is why pulmonary embolism remains the number one preventable death in hospitalized patients.
What is happening in the United States to overcome this problem is this type of ‘pay-for-performance’ that is going on. So, hospitals are going to get reimbursed based on the use of prophylaxis in their patients to try and promote the uptake of guidelines. We have all of these guidelines, but they are not being put into practice and it is really important, in both surgical and medical patients, that they are put into practice because patients are dying of pulmonary embolism, which is a potentially preventable disorder.
The surgeon general was supposed to be issuing a call to action on deep vein thrombosis, but this has been delayed. The bottom line is that this is a major problem and we are not doing enough to prevent it. The guidelines are there, but physicians are not following them. I think part of the problem is that it is sometimes hard to identify which patients are at risk, but in my opinion it could be made easy by saying that virtually any medical or surgical patient is at risk and you need a reason not to use prophylaxis rather than a reason to use it. Essentially, the bottom line is that the risk of pulmonary embolism is probably higher in surgical patients than medical patients, but it is still significant in medical patients, and about only half of patients who should be getting prophylaxis are getting it—it varies a bit from country to country—but we all need to do better.
– Jeffrey Weitz, MD
Director, Henderson Research Centre in Hamilton, Ontario, Canada
The ENDORSE study has several strengths. It is a global project that included a very large number of patients from academic and community centers. There was stringent training of study personnel to standardize data collection and the 2004 American College of Chest Physicians’ guidelines were used as the ‘gold standard’ for identifying patients who should receive in-hospital prophylaxis.
Although several retrospective cohort studies already have shown a low level of physician compliance with prophylaxis prescription, this cross-sectional study confirms that poor compliance with recognized practice guidelines is a global issue. This is important because it suggests that there might be similar obstacles across geographic, cultural and health care funding boundaries that lead to under utilization of prophylaxis. If that is true, then it can be postulated that shared solutions might be possible. To find such solutions, national, peer-reviewed funding bodies need to combine resources to promote and facilitate research across international borders.
Like other observational studies, this study has limited impact on clinical practice. It is, however, another reminder that physicians need to pay more attention to thromboprophylaxis in hospitalized patients. It also draws attention to the gap between medical research and medical practice, and reminds us that it is wrong to assume that scientific knowledge alone will lead to the practice of evidence-based medicine.
So what are the next steps we need to take in order to improve patient care? Obviously, we have to move beyond simply documenting that physicians are not doing what we are supposed to be doing and ask why we aren’t doing it. We then need to figure out how to overcome these problems and provide solutions or tools that are clear, simple and durable. Most importantly, we need to ask additional questions about what it is that we should be doing. For example, does prophylaxis compliance correlate with clinical outcome? In other words, does a low level of prophylaxis actually lead to unfavorable outcomes for patients? Although a recent trial demonstrated that a computerized alert system improved prophylaxis prescription rates in hospitalized medical patients and this was associated with a reduction in thrombotic event, it is an untested assumption that failure to follow the 2004 ACCP guidelines on prophylaxis leads to clinically significant thrombotic disease.
The ENDORSE study would have made a more important contribution if it had studied the association between compliance and thrombosis burden. This study also did not look at the duration of prophylaxis received by patients. Given that the length of hospital stay is shortening in many countries, it is important to know if a shorter duration of prophylaxis has any clinical significance. If it does, then improving physician compliance with in-hospital prophylaxis alone probably will not reduce thrombosis burden in the community. It is unfortunate that the ENDORSE study was not designed to answer these relevant questions.
The ENDORSE study serves as a useful benchmark for reference and for designing future studies to evaluate interventions to improve compliance. The time has come for bridging that gap between knowledge and action.
– Agnes Lee, MD, MSc, FRCPC
Associate professor of medicine at McMaster University in Hamilton, Ontario, Canada