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 in the Premier's Perspective national inpatient administrative database. The study period was January 2002 through September 2005. All of the patients were at least 40 years old, 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 the patients received some form of VTE prophylaxis. But only 34% received appropriate prophylaxis in keeping with ACCP guidelines, which since the mid-1980s have been the acknowledged gold standard, said 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, an increasingly high-visibility issue in recent years, 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 try to educate passengers about the problem on long international flights.
To see whether increased public attention to VTE has been accompanied by improvement in rates of appropriate prophylaxis, the researchers analyzed nearly 3 years of data quarterly. The rate increased only modestly, from nearly 30% in early 2002 to 40% in late 2005.
The low rate of adherence to VTE prophylaxis “is a significant concern for us across the nation,” Dr. Amin said.
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.
The investigators are now preparing individual performance reports for each of the 227 participating hospitals to use in their quality improvement programs. They are also reanalyzing the data to see how prophylaxis rates correlate with outcomes.
In addition, they are updating their results by incorporating adherence rates to the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy guidelines. In the initial study, the investigators used the sixth version of the guidelines because it was in force for most of the study period.
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