Thromboembolism Prevention Is Underutilized

LONDON, Feb. 1 -- Hospital patients at risk for venous thromboembolism don't receive appropriate preventive care, no matter how developed a country they live in, researchers here said.

More than 40% of surgical patients and 60% of medical patients at risk for venous thromboembolism in a large international study failed to receive prophylaxis as recommended by the American College of Chest Physicians, reported Alexander T. Cohen, M.D., of King's College Hospital, and colleagues in the Feb. 1 issue of The Lancet.

Some 5% to 10% of overall inpatient mortality is attributed to pulmonary embolism. It is the leading preventable cause of death in hospitals, Dr. Cohen and colleagues said.

"Our data show that, globally, a large proportion of hospitalized individuals -- both surgical and medical -- are at risk for venous thromboembolism, and that recommended venous thromboembolism prophylaxis is underused," they wrote.

The researchers recommended that hospitals adopt more aggressive strategies to identify and treat at-risk patients.

Their results emerged from the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study, involving chart reviews of each hospital's inpatients on a single specified day.

The analysis took in 68,183 inpatients at 358 randomly selected hospitals in 32 countries.

The patients included 30,827 surgical patients and 37,356 medical patients. Patients in the United States, western Europe, and Australia accounted for about half the sample. Less developed countries on every continent provided the rest.

Of the surgical patients, 64.4% (95% CI 63.8% to 64.9%) were at risk for venous thromboembolism according to consensus guidelines. The corresponding figure for medical patients was 41.5% (95% CI 41% to 42%).

Recommended prophylaxis includes anticoagulants (low molecular weight heparin most commonly), mechanical compression (intermittent pneumatic compression or graduated compression stockings most commonly), or antiplatelet agents, depending on bleeding risk.

Only 58.5% of at-risk surgical patients (95% CI 57.8% to 59.2%) and 39.5% of at-risk medical patients (95% CI 38.7% to 40.3%) received the recommended preventive treatment, Dr. Cohen and colleagues said.

The researchers found tremendous variability between countries. For example, 20% of at-risk medical patients and 26% of at-risk surgical patients in Russia received the recommended prophylaxis, whereas German hospitals provided the recommended treatment to 70% of medical and 92% of surgical patients.

The lowest rates were generally in the poorest countries, such as Bangladesh, where 3% of at-risk medical patients and 0.2% of at-risk surgical patients were given the recommended prophylaxis.

In the U.S., recommended prophylaxis was given to 48% of at-risk medical patients and 71% of at-risk surgical patients.

For medical patients with active malignancy and ischemic stroke, the rate of prophylaxis was 37%. Dr. Cohen and colleagues noted that this was below the overall average for medical patients even though these conditions confer very high risk for venous thromboembolism.

When the analysis was expanded to include any venous thromboembolism prophylaxis, it added only a few percentage points both overall and in nearly every individual country.

In the international totals, 48% of at-risk medical patients and 64% of at-risk surgical patients were given any kind of preventive treatment.

Dr. Cohen and colleagues said the higher rates of appropriate prophylaxis in surgical patients probably stem from better provider awareness and simpler assessment related to venous thromboembolism risk.

They acknowledged that individual patient factors such as bleeding risk may have driven decisions on preventive therapy.

"However, the low use of venous thromboembolism prophylaxis cannot be accounted for solely because of relative or absolute contraindications to anticoagulant prophylaxis, because these patients could have received ... recommended forms of mechanical prophylaxis," they pointed out.

Limitations of the study included its cross-sectional design, reliance on chart analysis, and lack of information on prophylaxis covering patients' entire hospital stay.

In an accompanying commentary, Walter Ageno, M.D., and Francesco Dentali, M.D., of the University of Insubria in Varese, Italy, said the ENDORSE results confirm earlier studies that found low rates of compliance with guidelines on venous thromboembolism prophylaxis.

They said that the low compliance could be explained by "ongoing disagreement about venous thromboembolism risk among practicing clinicians."

Drs. Ageno and Dentali noted that management guidelines for conditions such as heart failure and stroke do not uniformly recommend drug-based venous thromboembolism prophylaxis.

They called the lack of consensus "an important limitation of venous thromboembolism prophylaxis by general surgeons, urologists, and others.

For local programs to succeed in increasing prophylaxis rates, Drs. Ageno and Dentali added, medical and surgical societies first need to agree on guidelines for its proper use.