In the multinational IMPROVE study,[14
] it showed that only 60% of medical patients who are eligible for prophylactic antithrombotic therapy indeed received it. However, this percentage is much lower 16% in acutely ill hospitalized medical patients in Canada.[15
In our study, we found that only 36.5% of the patients who where eligible for prophylactic antithrombotic therapy received it. This is very close to the finding of AVAIL ME study which included 200 patients from Saudi Arabia,[16
] and found that VTE prophylaxis and guidelines applications ranging from (24-84%) among different subgroup.
The surgical patients in our study received prophylactic antithrombotic therapy significantly more than medical patients (P
> 0.01); 44.1% and 21.7%, respectively. Use of prophylactic antithrombotic therapy in both medical and surgical patients, is found to be only 35-42% of patients in the highest risk groups.[17
] However, results of the ENDORSE study which included 467 patients from the Middle East region (Kingdom of Saudi Arabia and the United Arab of Emirates) showed a wide range for surgical patients receiving prophylactic antithrombotic therapy; such that 0.2-92% of surgical patients received appropriate care compared to 3-7% of medical patients.[13
] It is to be noted that medical patients were termed as having “double trouble”, because they have higher proportions of VTE risk factors and prophylaxis for them is omitted more commonly therefore they would experience higher rate of VTE.[20
Although our Figures for thromboprophylaxis are in general lower than the reported numbers in the literature outside the Middle East region, the low incidence stays in accordance with many studies conducted at different countries, indicating the extreme underuse of thromboprophylaxis. Our study raises the necessities of improving the awareness of VTE risk and deploying the guidelines with special attention to medical patients.
We found that confirmed VTE accounts for 1.9% of hospital mortality within a period of 1 year. Some studies pointed to the under estimation of mortality rates caused by PE[21
] due to methodological reasons i.e., evaluating patients survival few hours after the onset of symptoms not to mention the possibility of missing clinical diagnosis as evidenced by the high incidence of VTE in autopsy studies.[7
] In comparison, our study is limited by unavoidable inability to perform autopsy in at least 320 cases with clinical diagnosis of VTE which would increase mortality share due to VTE within total hospital mortality.
Patients who received prophylactic antithrombotic therapy have mortality rate as low as 3.1% compared to those who have not received it (31%). The rational for the use of prophylactic antithrombotic therapy is based on solid principles and scientific evidence[24
] with evident benefits.[1
] The lower mortality of surgical patients in our study than medical patients is attributed to the higher rates of surgical patients receiving prophylactic antithrombotic therapy compared to medical patients such issue can be applied to the subgroup analysis based upon risk stratification.
The mortality of patients with DVT alone is lower than the patients with DVT who progressed to PE or patients who presented with PE only. This is thought to be related to the VTE prophylactic treatment. We may conclude that prophylactic antithrombotic therapies improve survival and would prevent DVT patients from progressly to PE.
It is of great concern in our study to find that not all of patients who survived their episode of VTE were discharged with anticoagulation therapy (97.2%). Of them, 83.7% only were adherent to it after discharge. Usage of anticoagulation therapy for 3 months or longer after DVT reduces recurrence from 25% to 4% or less.[25
] Patients with PE are very likely to die from recurrent PE than DVT. During the first 3 months of anticoagulation therapy, the risk of fatal subsequent PE is 1.5 in patients with previous PE versus 0.4 in patients with previous DVT.[11
] According to ACCP guideline, patients should be treated with anticoagulation therapy for at least 3 months if they had reversible risk factors and at least for 6 months if they had idiopathic PE.[26
] So comparing guideline with practice, there is a gap in prescription and a gap in adherence. Physicians should be directed towards implementing ACCP guideline. Moreover, they should instruct and educate their patients in collaboration with other healthcare providers to be adherent to prescribed anticoagulation therapy. The benefits of using and adhering to anticoagulation therapy in prevention of subsequent recurrence of VTE events should be an inseparable part within the management alliance between patients and healthcare providers.
King Fahad General Hospital is one of the biggest Ministry of Health hospitals in the Kingdom of Saudi Arabia. The elicited underuse of thromboprophylaxis is likely to be prevalent in all hospitals of Ministry of Health and represent the gap between guideline and application. In the AVAIL ME study, the authors suggested the use of several active strategies such as “regularly reminding clinicians to treat patients at VTE risk, electronic alerts for physicians about patients at risk, and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes” in addition to include those who are in position to assess VTE risk factors, namely clinical pharmacists and nurses and then direct patients to ask for prophylaxis. Based upon its prospective nature, most hospitals involved in the AVAIL ME study, start initiatives of carful planning to control the problem. Hospitals begin to implement educational sessions targeting practicing physicians and staff and start efforts toward changing guidelines to hospital policy.
From our perspective, all active strategies and methods used should be implemented within a system to be applied in all hospitals of Ministry of Health and its application should be enforced through health authorities.
We are aware of the limitations in our study, being a retrospective in a single hospital and our inability to perform autopsy to reach a more accurate mortality rate but we do not think that such limitation would impact the results. Nevertheless, such limitation in combination with the results and recommendations ought to emphasize the role of health authorities to consider enforcing VTE prophylaxis guideline application.