Thromboprophylaxis as a Common Part of Care for At-Risk Patients Requiring Hospitalization: Yes or No?
The proportion of patients requiring hospitalization who are at high risk of developing thromboembolic disease is relatively high. However, not all of these patients have this risk identified and thromboprophylaxis initiated.
Insidious nature of VTE lies in underestimating the risk
Venous thromboembolism (VTE) is among preventable causes of increased morbidity, but unfortunately also mortality, in patients requiring hospitalization. According to published studies, up to 42% of hospitalized patients have a moderate to high risk of developing VTE. Autopsy data suggest that VTE contributes to more than 10% of deaths among people requiring hospitalization. In many cases, VTE was not diagnosed before death. Despite being a common, often life-threatening condition in patients hospitalized for other reasons, determining the presence or risk of VTE, and initiating prevention, is not always adequate and sufficient during hospitalization.
Thromboprophylaxis, most commonly using low-molecular-weight heparins (LMWH), is, according to many clinical studies and experiences, a safe and effective option for preventing VTE, especially in high-risk patients.
Israeli experiences
A retrospective study by Israeli authors examined the frequency of VTE risk assessment in routine practice, the proportion of patients for whom thromboprophylaxis might be considered, and those who actually received it. Records of individuals hospitalized in one department (3000 in 2013; 1000 in 2018) were examined. VTE diagnosis was made based on clinical presentation.
The average age of patients was 67.95 ± 21.56 years, with slightly more women (52.6%). Patients receiving thromboprophylaxis or regular anticoagulation for another reason (prior to admission or as part of treatment for the condition they were hospitalized for) were excluded. After evaluating the reasons for their admission and their condition, it was found that 21% of them were suitable for consideration of thromboprophylaxis.
The frequency of VTE risk assessment significantly increased after it became part of Israel's so-called national quality of care parameters in 2016. However, the actual proportion of patients treated from all those suitable for thromboprophylaxis remained low (22% in 2013; 46% in 2018). Patients who received thromboprophylaxis were in a more severe condition, hence objectively sicker compared to patients who, based on risk assessment, should have received thromboprophylaxis but did not. The rate of symptomatic VTE occurrence was low (up to 0.55%). No serious bleeding was recorded after LMWH administration.
Conclusion
The authors conclude that despite about one-fifth of patients requiring hospitalization in internal departments would be suitable for considering thromboprophylaxis, the actual proportion of those receiving this prophylaxis is lower, and treatment often begins only for very sick patients. There is a significant need to increase efforts to identify all patients at high risk of developing VTE, and this assessment should become a standard part of care. If such a patient is identified, the benefits and potential risks of thromboprophylaxis must be very carefully considered, especially with regard to the morbidity and mortality associated with this potentially preventable complication.
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Source:
Mahlab-Guri K., Shaher Otman M., Replianski N. et al. Venous thromboembolism prophylaxis in patients hospitalized in medical wards. A real-life experience. Medicine (Baltimore) 2020 Feb; 99 (7): e19127, doi: 10.1097/MD.0000000000019127.
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