Title: VTE Prophylaxis in the Hospitalized Patient: Importance and Strategies for Improved Compliance
1VTE Prophylaxis in the Hospitalized Patient
Importance and Strategies for Improved Compliance
- Andrew H. Dombro, M.D.
- Instructor of Medicine
- Division of General Internal Medicine, Hospital
Medicine Section - University of Colorado Health Sciences Center
2Overview
- Background / Prevalence of VTE
- Benefits / Rationale for VTE prophylaxis
- Identification of hospitalized patients most at
risk - Methods of VTE prophylaxis
- National Consensus Standards for Prevention and
Care of VTE (CMS as well?) - Factors related to under-use of established
guidelines - Strategies to improve compliance
3Background / Prevalence of VTE
- PE is responsible for up to 200K deaths per year
in the United States¹ - PE remains the most common preventable cause of
hospital death, accounting for up to 10² - DVT/PE is much more common in the hospitalized
patient -- medical and surgical³ - 1. Horlander, KT, Mannino, DM, Leeper, KV. Arch
Intern Med 2003 1631711 - 2. Pendleton R et al. Am J Hemat.
200579229-237. - 3. Edelsberg J et al. Am J Health Syst Pharm
2006 63 16S-22S
4Background / Prevalence
- VTE is more than 130 times greater among
hospitalized patients than community residents¹ - half of community-based cases nursing home
patients or within 90 days of hospital discharge - 60 of all cases occurred in either hospitalized,
recently d/cd, or NH patients! - Hospitalization for acute medical illness is
associated with up to an 8-fold increase in
relative risk for VTE - 1. Heit, JA, Melton, LJ, Lohse, CM, et al. Mayo
Clin Proc 2001 76 1102
5Background / Prevalence
- Death occurs in about 6 of DVT cases within one
month of diagnosis1 - Death occurs in about 12 of PE cases within one
month of diagnosis1 - Up to 25 of distal DVT can propagate into
proximal DVT² - Pulmonary emboli are detected in approximately
50 of patients with proximal DVT² - Recurrent DVT
- Can occur in 30 of DVT patients within 10 years
after initial treatment³ - 1. American Heart Association. Heart Disease and
Stroke Statistics 2005 Update. - 2. Anand, SA et al. JAMA. 19982791094-1099.
- 3. Prandoni P et al. Haemotologia 2007 92
199-205
6Background / Prevalence¹
- Without prophylaxis, overall DVT incidence in
hospitalized medical and general surgical
patients is 10-40 - 40-60 following major orthopedic surgery
- Without prophylaxis, fatal PE occurs with the
following frequency in hospitalized patients - 0.1-0.8 undergoing elective general surgery
- 2-3 undergoing elective hip replacement
- 4-7 undergoing surgery for fractured hip!
- 1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S
7Background / Prevalence
- Without prophylaxis, reported VTE occurrence in
the ICU ranges between lt10 to nearly 100!! - Virtually all critical care patients are at
moderate to high risk - Up to 10 to 15 of patients with cancer may
develop a VTE1 - Malignancy independent factor for decreased early
and late survival after VTE event² - 1. Viale PH, Schwartz RN. Clin J Onco Nurs.
20048455-461. - 2. Heit JA et al. Arch Intern Med.
1999159445-453
8Consequences of Unprevented VTE
- Fatal PE -- usually occurs without warning and
often with no potential to resuscitate¹ - Patient discomfort associated with VTE
- Initial pain and discomfort
- Post-thrombotic syndrome (PTS)²
- Chronic Thromboembolic Pulmonary Hypertension
(CTPH)³ - spent in the investigation of suspected and
treatment of documented VTE - Risk of treatment once VTE occurs
- Increased length of initial hospital stay
- More frequent hospital readmission
- Increased future risk of VTE (4)
- 1. Anderson FA et al. Arch Intern Med 1991 151
933-8 - 2. Büller, HR et al. Chest. 20041264018-4288.
- 3. Pengo V et al. N EnglJ Med. 20043502257-2264.
- 4. Heit JA et al. Arch Intern Med 2000 160761-8
9Benefits / Rationale of VTE Prophylaxis
- DVT and PE are prevalent and serious
complications1 - Difficult to predict with any certainty which
patients will develop VTE² - Patients can experience VTE weeks after surgery2
- Clinical consequences of VTE, including
mortality, are common3 - Health burden associated with VTE is expected to
grow dramatically during coming years, in part
due to aging population (4) - 1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S. - 2. White RH et al. Arch Intern Med.
19981581525-1531. - 3. Pengo V et al. N Engl J Med.
20043502257-2264. - 4. Stein PQ et al. Arch Intern Med 2004.
1642260-65
10Benefits / Rationale of VTE Prophylaxis¹
- Hospital-acquired DVT/PE is usually clinically
silent --only 1/3 present with classic symptoms² - Overall incidence likely underestimated³
- Screening, either by physical exam or noninvasive
testing, is not clinically effective or cost
effective - Prophylaxis is far more effective for preventing
death/morbidity from VTE than is treatment of
established disease - 1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S - 2. Turkstra F et al. Ann Intern Med 1997 126
775-81 - 3. Kyrle PA et al. Lancet 2005 365 1163-74
11Benefits / Rationale of VTE prophylaxis
- Effective and safe prophylactic measures are
available for most high-risk patients (1,2) - pharmacologic prophylaxis lowers the risk of
symptomatic and asymptomatic VTE in medical
patients by 50-75! - little or no increase in rates of clinically
important bleeding complications - Based on solid principles and scientific evidence
from large numbers of randomized clinical trials³ - Most hospitalized patients have one or more risk
factor for VTE and importantly, these are
cumulative(4) - 1. Gerotziafas, GT, Samama, MM. Curr Opin Pulm
Med 2004 10356 - 2. Clagett, GP, Reisch, JS. Ann Surg 1988
208227 - 3. Patel R et al. J Crit Care 2005 2034-7
- 4. Dorfman, et al. J Clin Pharm Therap 2006 31
455-9
12Benefits of VTE Prophylaxis
- Appropriate VTE prophylaxis achieves two very
desirable results - Improved patient outcomes
- Reduced costs
13Risk Factors Predicting VTE
- No definitive way to predict which patients will
acquire VTE1 - Risk factors for VTE have been reported1,2
- Preexisting and surgical risk factors for VTE can
be cumulative for patients undergoing surgery3 - Patients undergoing hip or knee replacement or
hip fracture surgery are among those at highest
risk1
1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S. 2. Heit JA et al Arch Intern
Med. 2000160809-815. 3. Geerts WH, et al.
Chest. 2001119132S-175S.
14VTE Risk Medical and Surgical Patient
Characteristics (1,2)
- History of VTE
- Family history VTE
- Malignancy
- Increased age (possibly 41)
- CHF
- AMI
- Ischemic CVA
- Pregnancy/Postpartum
- Infection/Sepsis
- Prolonged immobilization
- Acute/chronic lung disease
- Hypotension/shock
- Inflammatory disease (including IBD)
- Estrogen therapy
- Obesity (BMIgt25)
- Tobacco use
- Varicose veins
- Inhibitor deficiency states
- Antiphospholipid Abs
- Protein C/S
- Factor V Leiden (3-7)
- Prothrombin Gene Mutation (2)
- AT III
1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S Heit JA et al. Arch Intern Med.
2000160809-815. 2. Kikura, M, Takada, T, Sato,
S. Preexisting morbidity as an independent risk
factor for perioperative acute
thromboembolism syndrome. Arch Surg 2005
1401210
15Surgical Risk Factors
- Procedure
- Surgical site
- Surgical technique
- Anesthetic
- Duration of procedure
- Presence of infection
- Postoperative immobilization
16Virchows Triad¹
- Vascular Injury²
- Recurrent DVT/PE
- Surgery
- Cancer treatment
- Trauma
- Venipuncture
- Atherosclerosis
- IV drug administration
Venous Stasis² Obesity Immobility Chronic heart
disease Age above 40
Hypercoaguable State2 Hereditary risk
factors Bleeding disorders Malignancy
Risk Factors are Cumulative3
1. Anderson, FA et al. Circulation.2003107I-9--I
-10. 2. Viale PH, Schwartz RN. Clin J Onco Nurs.
20048455-461. 3. Rosendaal FR. Lancet.
19993531167-1173.
17Extended VTE Risk Following Hospital Discharge
- VTE can occur for up to 3 months after total knee
and hip arthroplasty1 - Hypercoagulability can persist for 6 weeks after
hip fracture2 - Venous function was significantly impaired for up
to 42 days following hip fracture surgery3 - Recurrent DVT
- 30 of DVT patients 8 to 10 years after initial
treatment4
1. White RH et al. Arch Intern Med.
19981581525-1531. 2. Wilson D et al. Injury.
200132765-770. 3. Wilson D et al. Injury.
20023333-39. 4. American Heart Association.
Heart Disease and Stroke Statistics 2005 Update.
18Features of an Ideal VTE Prophylaxis Regimen
- Effective
- Safe
- Good compliance
- Easily administered
- No laboratory monitoring needed
- Cost effective
19Methods of VTE Prophylaxis
- Mechanical
- Graduated Compression Stockings (GCS)
- Intermittent Pneumatic Compression Devices (IPC)
- Pharmacologic
20Mechanical Prophylaxis
- Disadvantages
- No mechanical prophylaxis options have been shown
to reduce the risk of death or PE1 - Must be worn continuously pre-, intra- and
postoperatively for 72 hours1 - GCS can cause impairment in tissue oxygenation
(PVD)3 - GCS need to be sized and fitted properly3
- Advantages
- Lack of bleeding potential1
- No clinically important side effects
- No laboratory monitoring needed2
- IPC stimulates endogenous fibrinolytic activity
(reduces plasminogen activator inhibitor-1 levels
by unknown mechanism) 2
1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S. 2. Davis P. J Ortho Nurs.
2004850-56. 3. Agu O et al. Br J Surg.
199986992-1004.
21Pharmacologic Prophylaxis
- Aspirin NOT recommended as sole prophylaxis
agent1 - Low-dose unfractionated heparin (LDUH)2
- Low molecular weight heparin (LMWH)2
- Enoxaparin
- Dalteparin
- Tinzaparin
- Vitamin K antagonist (VKA)1
- Warfarin
- Factor Xa inhibitor2
- Fondaparinux
Choice of pharmacologic agent depends on VTE risk
reduction, complication rate and proper dosing of
agent2
1. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S. 2. Pendleton R et al. Am J
Hemat. 200579229-237.
22Risky Business
- The majority of hospitalized medical and surgical
patients are at increased risk of VTE² - Risks appear to be cumulative¹
- Risk stratification is cumbersome, not adequately
validated, and therefore not as widely
agreed-upon in medical patients as in surgical
patients - Guidelines, however, do exist (2,3)
- 1. Dorfman, et al. J Clin Pharm Therap 2006 31
455-9 - 2. Edelsberg, J et al. Am J Health-Syst Pharm
2006. 63 S16-S22 - 3. Geerts WH et al. Chest. 2004126(3
suppl)338S-400S.
23ACCP Recommendations (since 1986)
- Geerts, WH, et al. CHEST 2004 126 338s-400s
24VTE Prophylaxis Usage
- Varies markedly, overall remaining abysmally low
- Audit of 384 patients with VTE¹
- 201 (52) received prophylaxis (112
anticoagulation, 31 mechanical prophylaxis, 58
combination) - 183 (48) No prophylaxis
- 13 deaths due to PE
- One study showed that only 46 of hospitalized
medical patients, with risk factors for VTE,
received appropriate prophylaxis² - Various studies show a VTE prophylaxis rate in
surgical patients varying from 38 to 94 (3,4) - true even amongst orthopedic surgeons³
- 1. Goldhaber et al. Chest 20001181680-1684.
- 2. Ageno et al. Haematologia 2002 87 746-50
- 3. Stratton et al. Arch Intern Med 2000 160
334-40 - 4.Anderson et al. J Thromb Thrombol 1998 5
S7-S11
25VTE Prophylaxis Usage
- Even when used, guideline recommendations often
not followed - Grade IA ACCP recommendations were followed from
45 (hip fracture surgery) to 84 (elective THR)
of the time¹ - Retrospective study overall compliance rate
13.3 in greater than 120,000 hospital
admissions² - 2.8 Neurosurgery
- 52.4 Orthopedic Surgery
- 13.3 Medicine
- 1. Statton et al. Arch Intern Med 2000 160
334-40 - 2. Yu HT et al. Am J Health Syst Pharm 2007. 64
69-76
26VTE Prophylaxis Usage
- Hospitalists found superior!¹
- Pneumonia Care VTE prophylaxis
- 96.0 vs. 61.9
- 1. William D et al. Am J Manag Care 2007.
13129-32
27Contributing Factors to Under Use Physician
Related (1,2)
- Lack of awareness / unfamiliarity with guidelines
- Perception that VTE is not a significant or
frequent problem - Patients will be ambulatory soon enough
- Concern over bleeding risks (surgical sites and
elsewhere) - Guidelines seem complicated or difficult to apply
- Patients so ill on admission that VTE concerns
dont hit the radar screen - More difficult to change habits than to
incorporate a new habit - 1. Geerts et al. Chest 2004 126 338S-400S
- 2. Cabana et al. JAMA 1999 282 1458-65
28Contributing Factors to Under use --
Environmental¹
- Not under physicians direct control, such as
acquisition of new resources or facilities - Lack of time
- Financial constraints (increased practice costs,
lack of reimbursement) - Increased legal liability
- 1. Cabana et al. JAMA 1999 282 1458-65
29Contributing Factors to Under Use Institution
Related¹
- Lack of standardized order sets for VTE
prophylaxis - Lack of user-friendly patient risk assessment
tools/mechanisms - Logistical limitations of health care management
systems, for instance lack of medical informatics
systems with computerized prompts - 1. Cabana et al. JAMA 1999 282 1458-65
30National Consensus Standards for Prevention and
Care of VTE
- JCAHO and National Quality Forum (NQF) -- project
began 9/04 - Eight different measures have been recommended by
the Technical Advisory Panel (TAP) for pilot
testing this year. Regarding VTE prophylaxis,
these include - VTE Risk Assessment (RA)/Prophylaxis within 24
hours of hospital admission - VTE Risk Assessment (RA)/Prophylaxis within 24
hours of transfer to ICU - Incidence of Potentially Preventable
Hospital-acquired VTE
31Center for Medicare and Medicaid Services
- CMS is strongly considering using VTE prophylaxis
as a core safety compliance and performance
measure - This will directly affect hospital / physician
reimbursements (i.e., pay for performance)
32The Literature What Has Worked?
- Respected leaders within institutions¹
- Clinical audits with feedback (2,3)
- Clinical decision support tools (83 ? 95) (4)
- Clinical guidelines combined with chart
monitoring (5) - Nursing/patient education for increased
compliance with SCDs (6) - Establishment of protocols, combined with staff
education and a daily computer driven reminder
(reporting tool) for morning rounds in ICU (7) - Computer based reminders (8)
- 1. Winkler, et al. Arch Intern Med 1985
145314-7 - 2. Williams, et al. Ann R Coll Surg Engl 1997
7955-7 - 3. Greco, et al. NEJM 1993 329 1271-4
- 4. Durieux, et al. JAMA 2000 283 2816-21
- 5. Phillips, et al. Thromb Haemost 1997 77
283-8 - 6. Stewart, D et al. Ann Surg 2006. 72 921-3
- 7. Wahl, WL et al. Surgery 2006. 140 648-9
- 8. Patterson R. Proc AMIA Symp 1998. 573-6
33Future Directions -- UCHSC
- Increase overall VTE prophylaxis compliance
- Improved methods of risk stratification
- Increased adherence to established guidelines
- Proposed results
- Improved patient safety and outcomes
- Improved adherence to JHACO / CMS standards and
institutionally established compliance
targets/goals
34Proposed Study - UCHSC
- Prospective historical controlled trial
- Develop simple, useable method of VTE risk
stratification - Utilize prompts written and eventually
electronic - Measure compliance rates compared to historic
rates
35Methods
- Using established risk factors, develop simple,
useable method of risk stratifications for
clinicians, using methods that have proved
effective¹ - Initially paper admission/transfer orders
- With CPOE, add as pop-up²
- Include current ACCP guidelines
- Use medication reconciliation sheets/orders as
reminder - Forms would be mandatory for all
admissions/transfers - Again, with CPOE, would be contained therein
- Measure rates of physician compliance and choice
of method on high-risk patients (2 or more risk
factors) pre and post implementation - 1. McCaffrey R et al. Worldviews Evid Based Nurs
2007 414-20 - 2. Paterno MD et al. AMIA Annu Symp Proc 2006
1058
36General Conclusions
- VTE prophylaxis is justified, low-risk, and
indicated in most hospitalized patients - Good for patients
- Good for hospitals
- Overall, VTE prophylaxis is under-utilized
- Hospitals and physicians will soon be judged on
compliance - Each hospital needs a standardized approach for
VTE prophylaxis to improve compliance - protocols, pre-printed orders, risk
stratification, etc. - Multi-disciplinary approach
- auditing
37Thanks