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1.  Are There Any Differences in the Clinical and Economic Outcomes Between US Cancer Patients Receiving Appropriate or Inappropriate Venous Thromboembolism Prophylaxis? 
Journal of Oncology Practice  2009;5(4):159-164.
Prophylaxis is often underused and inappropriately prescribed. This study compares the efficacy and cost of appropriate and partial prophylaxis in cancer patients at risk for VTE.
Purpose:
Despite evidence-based recommendations existing for the prevention of venous thromboembolism (VTE) in cancer patients, prophylaxis is often underused and inappropriately prescribed. This study compared the efficacy and cost of appropriate and partial prophylaxis in cancer patients at risk of VTE.
Methods:
Discharge records for inpatients age ≥ 40 years, with a primary cancer diagnosis, and receiving some form of American College of Chest Physicians (ACCP) –recommended therapy in the Premier Perspective database (Premier Inc, Charlotte, NC; January 2002 to December 2006) were categorized into appropriate (in accordance with ACCP recommendations) or partial prophylaxis (inappropriate type, insufficient dose, or insufficient duration of prophylaxis) groups. VTE events, death, 30-day readmission, major and minor bleeds, and hospital costs were compared between groups using univariate and multivariate regression analysis.
Results:
Of the 83,794 discharges included, only 16% received appropriate prophylaxis. Partial prophylaxis conferred a significantly increased risk in hospital-acquired VTE (odds ratio [OR], 3.09; 95% CI, 2.51 to 3.80; P < .001), in-hospital death (OR, 1.48; 95% CI, 1.29 to 1.69; P < .001), and 30-day VTE readmission (OR, 3.11; 95% CI, 1.54 to 6.26; P = .002) compared with appropriate prophylaxis. No major bleeds were recorded in the database and no difference was observed in the rates of minor bleeding. The total cost per discharge was higher for partial prophylaxis ($17,128) than appropriate prophylaxis ($15,384), with an adjusted mean difference of $1,275 in favor of appropriate prophylaxis.
Conclusion:
In cancer patients at risk of VTE, appropriate prophylaxis reduced the hospital costs and incidence of VTE, mortality, and VTE readmission compared with partial prophylaxis. Increased appropriate use of ACCP recommendations may reduce the clinical and economic burden of VTE.
doi:10.1200/JOP.0942002
PMCID: PMC2795419  PMID: 20856628
2.  Educating surgical patients to reduce the risk of venous thromboembolism: an audit of an effective strategy 
JRSM Short Reports  2011;2(12):97.
Objectives
Venous thromboembolism (VTE) causes approximately 25,000 deaths each year from hospital-acquired thrombosis in the UK. Patient understanding of risk factors and preventive measures is important in preventing VTE. This audit was designed to assess surgical patient awareness and understanding of VTE risk factors and prophylaxis.
Design
A questionnaire was designed to assess preoperative patient understanding of components of the National Institute for Health and Clinical Excellence (NICE) guidelines. Leaflets were designed to address gaps in understanding and junior doctors were given guidance on patient education. A second group of patients completed the same questionnaire after introduction of the education system.
Setting
Worthing Hospital, UK.
Participants
One hundred and twenty-one patients due to undergo major general surgery. Seventy-one participants completed the questionnaire prior to implementation of the education system, and 50 after.
Main outcome measures
Improvement in patient awareness of VTE, its risk factors and its preventative measures (in response to the education system).
Results
Following the introduction of a targeted VTE education system, there was a significant improvement in the awareness of VTE to 90% (P < 0.01), its signs to 80% (P < 0.01), and its preventative measures to 84% (P < 0.01).
Conclusions
Patient education is of paramount importance in reducing the risks of VTE perioperatively. A simple method of introducing patient education at pre-assessment clinic and as part of their discharge planning, for major elective surgery, is an effective system in improving patient understanding of VTE, its risk factors and the importance of prophylaxis. It may also increase compliance.
doi:10.1258/shorts.2011.011116
PMCID: PMC3265834  PMID: 22279607
3.  The implementation of nice guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England 
Background
Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis.
The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety.
Methods
A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.
Results
Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97).
Conclusions
The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.
doi:10.1186/1472-6963-13-203
PMCID: PMC3716796  PMID: 23734903
Venous thromboembolism (VTE); Implementation strategies; NICE; Patient safety
4.  Thromboprophylaxis use in medical and surgical inpatients and the impact of an electronic risk assessment tool as part of a multi-factorial intervention. A report on behalf of the elVis study investigators 
Venous thromboembolism (VTE) is a major source of morbidity and mortality for both surgical and medical hospitalised patients. Despite the availability of guidelines, thromboprophylaxis continues to be underutilised. This study aims to assess the effectiveness of an electronic VTE risk assessment tool (elVis) on VTE prophylaxis in hospitalised patients. A national, multicentre, prospective clinical audit collected information on VTE prophylaxis and risk factors for VTE in 2,400 hospitalised patients (comprising of equal numbers of medical, surgical and orthopaedic patients). After auditing the standard care use of VTE prophylaxis in 1,200 consecutive patients (audit 1, A1), the elVis system was installed and a second audit (A2) of VTE prophylaxis was performed in a further 1,200 patients. The use of the electronic VTE risk assessment tool was low with 20.5% of patients assessed with elVis. The intervention, elVis plus accompanying education, improved the use VTE prophylaxis to guidelines by 5.0% amongst all patients and by 10.7% amongst high risk patients (adjusted odds ratio (AOR) 1.27 and 1.65 respectively). The use of elVis in A2 varied between hospitals and specialties and this resulted in marked heterogeneity. Despite this heterogeneity, patients assessed with elVis had 1.44 times higher AOR of being treated to guidelines compared to those who were not (P < 0.05). The use of elVis accompanied by staff education improved VTE prophylaxis, especially amongst high risk patients. To optimise the effectiveness and support enduring practice change electronic systems, such as elVis, need to be completely integrated within the treatment pathway.
doi:10.1007/s11239-011-0602-9
PMCID: PMC3170471  PMID: 21643821
Deep vein thrombosis; Venous thromboembolism; Pulmonary embolism; Guideline adherence; Prevention; Thromboprophylaxis
5.  Postoperative Venous Thromboembolism Prophylaxis by General Surgeons in a Developing Country: A Survey 
Thrombosis  2013;2013:873750.
Venous thromboembolism (VTE) is the most common preventable cause of hospital death. Several audits in the west have demonstrated that appropriate thromboprophylaxis is not being offered to a large number of surgical patients. Similar audits are lacking in the Indian population, and a perception exists among Indian surgeons that Indian patients are not susceptible to VTE. Hence we undertook a survey to analyze the existing knowledge and practice of VTE prophylaxis amongst general surgeons in India. A questionnaire-based survey was conducted on 100 active general surgeons. We found that 97% of surgeons had encountered VTE in their practice, and 49% had encountered mortality from pulmonary embolism. 64% of surgeons do not routinely score patients preoperatively for their VTE risk, and only 33% reported the presence of an institute-based protocol for the same. There was a wide disparity in the prophylaxis methods used for each risk group, particularly in the moderate-risk group. These findings suggest the need for adoption of institute-based protocols for prophylaxis and the evolution of Indian guidelines for VTE prophylaxis.
doi:10.1155/2013/873750
PMCID: PMC3818923  PMID: 24236232
6.  Venous thromboembolism prophylaxis for hospitalized medical patients, current status and strategies to improve 
Annals of Thoracic Medicine  2010;5(4):195-200.
Venous thromboembolism (VTE), comprising life-threatening pulmonary embolism (PE) and its precursor deep-vein thrombosis (DVT), is commonly encountered problem. Although most patients survive DVT, they often develop serious and costly long-term complications. Both unfractionated heparin and low molecular weight heparins significantly reduce the incidence of VTE and its associated complications. Despite the evidence demonstrating significant benefit of VTE prophylaxis in acutely ill medical patients, several registries have shown significant underutilization. This underutilization indicates the need for educational and audit programs in order to increase the number of medical patients receiving appropriate prophylaxis. Many health advocacy groups and policy makers are paying more attention to VTE prophylaxis; the National Quality Forum and the Joint Commission recently endorsed strict VTE risk assessment evaluation for each patient upon admission and regularly thereafter. In the article, all major studies addressing this issue in medical patients have been reviewed from the PubMed. The current status of VTE prophylaxis in hospitalized medical patients is addressed and some improvement strategies are discussed.
doi:10.4103/1817-1737.69104
PMCID: PMC2954373  PMID: 20981179
Deep vein thrombosis; heparin; low molecular weight heparin; pulmonary embolism; thromboprophylaxis
7.  Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study 
Thrombosis Journal  2004;2:3.
Background
Consensus Conferences and Guidelines for deep vein thrombosis prophylaxis have been published, which recommend the use of prophylactic heparins in patients with risk of venous thromboembolism (VTE). The aim of this study was the assessment of the prophylaxis of VTE and the adherence to accepted guideline recommendations throughout the hospital.
Methods
A cross-sectional study was carried out in a teaching hospital after guidelines were implemented. Patients' risk factors of deep vein thrombosis, risk categories of patients, and prophylaxis used in different wards were recorded. Appropriate adherence to the guidelines was analysed.
Results
Of 397 patients, prophylaxis was used in 231 patients (58%), and low-molecular-weight heparins (LMWH) were used in 224 of them (97%). Patients with prophylaxis had a higher mean number of risk factors (SD) than those without prophylaxis [3.1 (1.4) vs 1.9 (1.4); p < 0.05)]. Prophylaxis was used in 72% and 90% of moderate and high-risk patients respectively. Appropriate adherence to all guideline recommendations was observed in 42% of patients. Adherence to guidelines was high as regards the use of prophylaxis according to patients' risk factors (78%) and the use of appropriate types of prophylaxis (99%), but was low regarding appropriate heparin dosage (47%) and preoperative dosage (37%). Appropriate prophylaxis use was higher in critical care and surgical wards than in medical wards.
Conclusion
Prophylaxis of VTE is generally used in risk patients, but appropriate adherence to guidelines is less frequent and variable among different wards. Continuing medical education, discussion and dissemination of guidelines, and regular clinical audit are necessary to improve prophylaxis of VTE in clinical practice.
doi:10.1186/1477-9560-2-3
PMCID: PMC416491  PMID: 15059286
Embolism and Thrombosis; Venous Thrombosis; Preventive Medicine; Practice Guidelines; Heparin, Low-Molecular-Weight
8.  Practices to prevent venous thromboembolism: a brief review 
BMJ Quality & Safety  2013;23(3):187-195.
Background
Venous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of VTE prophylaxis in hospitals, with varying degrees of success. We reviewed key articles to assess the efficacy of different types of interventions to improve prescription of VTE prophylaxis for hospitalised patients.
Methods
We conducted a search of MEDLINE for key studies published between 2001 and 2012 of interventions employing education, paper based tools, computerised tools, real time audit and feedback, or combinations of intervention types to improve prescription of VTE prophylaxis for patients in hospital settings. Process outcomes of interest were prescription of any VTE prophylaxis and best practice VTE prophylaxis. Clinical outcomes of interest were any VTE and potentially preventable VTE, defined as VTE occurring in patients not prescribed appropriate prophylaxis.
Results
16 articles were included in this review. Two studies employed education only, four implemented paper based tools, four used computerised tools, two evaluated audit and feedback strategies, and four studies used combinations of intervention types. Individual modalities result in improved prescription of VTE prophylaxis; however, the greatest and most sustained improvements were those that combined education with computerised tools.
Conclusions
Many intervention types have proven effective to different degrees in improving VTE prevention. Provider education is likely a required additional component and should be combined with other intervention types. Active mandatory tools are likely more effective than passive ones. Information technology tools that are well integrated into provider workflow, such as alerts and computerised clinical decision support, can improve best practice prophylaxis use and prevent patient harm resulting from VTE.
doi:10.1136/bmjqs-2012-001782
PMCID: PMC3932749  PMID: 23708438
Quality improvement methodologies; Quality improvement; Decision support, clinical
9.  Changing practice: implementation of a venous thromboembolism prophylaxis protocol at an academic medical center 
Plastic and reconstructive surgery  2011;128(5):1085-1092.
Background
The Institute of Medicine has identified a “quality chasm” between existing evidence and actual clinical practice. The Venous Thromboembolism Prevention Study (VTEPS) has shown that enoxaparin prophylaxis is a safe and effective way to prevent post-operative venous thromboembolism (VTE). Here, we present a “how-to” guide for implementation of a VTE prophylaxis protocol.
Methods
The VTEPS prophylaxis protocol included provision of post-operative, prophylactic dose enoxaparin for the duration of inpatient stay. “Compliance” was considered at the individual patient level, and was defined as appropriate provision of protocol-appropriate enoxaparin prophylaxis.
Multiple simultaneous interventions to improve protocol compliance were undertaken. Both physician and physician assistant “champions” were identified. Interventions included staff and surgeon educational sessions, discussion of VTE-themed articles at journal club, and monthly email reminders specific to the protocol, among others. Compliance rates over time were compared using the chi-squared test.
Results
We reviewed medical records from 945 consecutive admissions to the plastic surgery service who met VTEPS eligibility criteria over a 30-month period. Initial education sessions significantly increased compliance over baseline (55% vs. 10%, p<0.001). After formal protocol adoption, compliance increased steadily over the first nine months and peaked by one year. In the absence of any direct intervention, compliance remained stable at 90% for the final 12 months of the study. This was significantly increased when compared to the period of time immediately following protocol adoption (90% vs. 77%, p<0.001).
Conclusions
This manuscript provides readers with a practical approach for implementation of a VTE prophylaxis protocol at their hospital.
doi:10.1097/PRS.0b013e31822b67ff
PMCID: PMC3204165  PMID: 21738084
system and process improvement; quality improvement system; evidence based medicine; implementation; champion; clinical protocol; venous thromboembolism; deep venous thrombosis; pulmonary embolus; plastic surgery
10.  Patterns of Non-Administration of Ordered Doses of Venous Thromboembolism Prophylaxis: Implications for Novel Intervention Strategies 
PLoS ONE  2013;8(6):e66311.
Background
Recent studies have documented high rates of non-administration of ordered venous thromboembolism (VTE) prophylaxis doses. Intervention strategies that target all patients have been effective, but prohibitively resource-intensive. We aimed to identify efficient intervention strategies based on patterns of non-administration of ordered VTE prophylaxis.
Methods and Findings
In this retrospective review of electronic medication administration records, we included adult hospitalized patients who were ordered pharmacologic VTE prophylaxis with unfractionated heparin or enoxaparin over a seven-month period. The primary measure was the proportion of ordered doses of VTE prophylaxis not administered, assessed at the patient, floor, and floor type levels. Differences in non-administration rates between groups were assessed using generalized estimating equations. A total of 103,160 ordered VTE prophylaxis doses during 10,516 patient visits on twenty-nine patient floors were analyzed. Overall, 11.9% of ordered doses were not administered. Approximately 19% of patients missed at least one quarter and 8% of patients missed over one half of ordered doses. There was marked heterogeneity in non-administration rate at the floor level (range: 5–27%). Patients on medicine floors missed a significantly larger proportion (18%) of ordered doses compared to patients on other floor types (8%, Odds Ratio: 2.4, p<0.0001). However, more than half of patients received at least 86% of their ordered doses, even on the lowest performing floor. The 20% of patients who missed at least two ordered doses accounted for 80% of all missed doses.
Conclusions
A substantial proportion of ordered doses of VTE prophylaxis were not administered. The heterogeneity in non-administration rate between patients, floors, and floor types can be used to target interventions. The small proportion of patients that missed multiple ordered doses accounted for a large majority of non-administered doses. This recognition of the Pareto principle provides opportunity to efficiently target a relatively small group of patients for intervention.
doi:10.1371/journal.pone.0066311
PMCID: PMC3683023  PMID: 23799091
11.  Venous thromboembolism prevention post neck of femur fractures – does it make a difference? 
Thrombosis Journal  2008;6:8.
Neck of femur fractures predispose patients to venous thromboembolism (VTE). NICE has issued guideline 46 to reduce this risk through the use of antithrombic agents. We audited our department's VTE practise by reviewing the clinical notes of 123 consecutive patients with no exclusions. We found our compliance to be a low 6%. We also found that patients were likely to be given low molecular heparin (LMWH) only during their hospital stay. Reasons for the low adherence were probably secondary to confusion caused by the multiple thromboprophylaxis protocols used in our department. The correlation between duration of heparin administration and length of hospital stay was due to logistical difficulty in administering VTE prophylaxis out of hospital setting.
doi:10.1186/1477-9560-6-8
PMCID: PMC2447826  PMID: 18582377
12.  Venous thromboprophylaxis in UK medical inpatients 
We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the datain changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice.
1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate riskof developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis—4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grandrounds, showed a significant increase to 31% inpatients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However,the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59).
We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increasethe overall proportion of patients receiving it. Wetherefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deepvenous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
PMCID: PMC1275999  PMID: 16260800
13.  Venous thromboembolism prophylaxis guideline implementation is improved by nurse directed feedback and audit 
Thrombosis Journal  2011;9:7.
Background
Venous thromboembolism (VTE) is a major health and financial burden. VTE impacts health outcomes in surgical and non-surgical patients. VTE prophylaxis is underutilized, particularly amongst high risk medical patients. We conducted a multicentre clinical audit to determine the extent to which appropriate VTE prophylaxis in acutely ill hospitalized medical patients could be improved via implementation of a multifaceted nurse facilitated educational program.
Methods
This multicentre clinical audit of 15 Australian hospitals was conducted in 2007-208. The program incorporated a baseline audit to determine the proportion of patients receiving appropriate VTE prophylaxis according to best practice recommendations issued by the Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism (ANZ-WP recommendations), followed by a 4-month education intervention program and a post intervention audit. The primary endpoint was to compare the proportion of patients being appropriately managed based on their risk profile between the two audits.
Results
A total of 8774 patients (audit 1; 4399 and audit 2; 4375) were included in the study, most (82.2% audit 1; and 81.0% audit 2) were high risk based on ANZ-WP recommendations. At baseline 37.9% of high risk patients were receiving appropriate thromboprophylaxis. This increased to 54.1% in the post intervention audit (absolute improvement 16%; 95% confidence interval [CI] 11.7%, 20.5%). As a result of the nurse educator program, the likelihood of high risk patients being treated according to ANZ-WP recommendations increased significantly (OR 1.96; 1.62, 2.37).
Conclusion
Utilization of VTE prophylaxis amongst hospitalized medical patients can be significantly improved by implementation of a multifaceted educational program coordinated by a dedicated nurse practitioner.
doi:10.1186/1477-9560-9-7
PMCID: PMC3080276  PMID: 21466681
14.  Educational outreach visits to improve venous thromboembolism prevention in hospitalised medical patients: a prospective before-and-after intervention study 
Background
Despite the availability of evidence-based guidelines on venous thromboembolism (VTE) prevention clinical audit and research reveals that hospitalised medical patients frequently receive suboptimal prophylaxis. The aim of this study was to evaluate the acceptability, utility and clinical impact of an educational outreach visit (EOV) on the provision of VTE prophylaxis to hospitalised medical patients in a 270 bed acute care private hospital in metropolitan Australia.
Methods
The study used an uncontrolled before-and-after design with accompanying process evaluation. The acceptability of the intervention to participants was measured with a post intervention survey; descriptive data on resource use was collected as a measure of utility; and clinical impact (prophylaxis rate) was assessed by pre and post intervention clinical audits. Doctors who admit >40 medical patients each year were targeted to receive the intervention which consisted of a one-to-one educational visit on VTE prevention from a trained peer facilitator. The EOV protocol was designed by a multidisciplinary group of healthcare professionals using social marketing theory.
Results
Nineteen (73%) of 26 eligible participants received an EOV. The majority (n = 16, 85%) felt the EOV was effective or extremely effective at increasing their knowledge about VTE prophylaxis and 15 (78%) gave a verbal commitment to provide evidence-based prophylaxis. The average length of each visit was 15 minutes (IQ range 15 to 20) and the average time spent arranging and conducting each visit was 92 minutes (IQ range 78 to 129). There was a significant improvement in the proportion of medical patients receiving appropriate pharmacological VTE prophylaxis following the intervention (54% to 70%, 16% improvement, 95% CI 5 to 26, p = 0.004).
Conclusions
EOV is effective at improving doctors’ provision of pharmacological VTE prophylaxis to hospitalised medical patients. It was also found to be an acceptable implementation strategy by the majority of participants; however, it was resource intensive requiring on average 92 minutes per visit.
doi:10.1186/1472-6963-13-398
PMCID: PMC3852069  PMID: 24103108
Educational outreach visit; Implementation science; Venous thromboembolism prevention
15.  Prevention and treatment of venous thromboembolism in patients with cancer 
Canadian Pharmacists Journal : CPJ  2012;145(1):24-29.e1.
Background: Many patients who experience a venous thromboembolic event have cancer, and thrombosis is much more prevalent in patients with cancer than in those without it. Thrombosis is the second most common cause of death in cancer patients and cancer is associated with a high rate of recurrence of venous thromboembolism (VTE), bleeding, requirement for long-term anticoagulation and poorer quality of life.
Methods: A literature review was conducted to identify guidelines and evidence pertaining to anticoagulation prophylaxis and treatment for patients with cancer, with the goal of identifying opportunities for pharmacists to advocate for and become more involved in the care of this population.
Results: Many clinical trials and several guidelines providing guidance to clinicians in the treatment and prevention of VTE in patients with cancer were identified. Current clinical evidence and guidelines suggest that cancer patients receiving care in hospital with no contraindications should receive VTE prophylaxis with unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH) or fondaparinux. Patients who require surgery for their cancer should receive prophylaxis with UFH, LMWH or fondaparinux. Cancer patients who have experienced a VTE event should receive prolonged anticoagulant therapy with LMWH (at least 3 months to 6 months). No routine prophylaxis is required for the majority of ambulatory patients with cancer who have not experienced a VTE event. Most publicly funded drug plans in Canada have developed criteria for funding of LMWH therapy for patients with cancer.
Conclusions: Evidence suggests that LMWH for 3 to 6 months is the preferred strategy for most cancer patients who have experienced a thromboembolic event and for hospital inpatients, but this is often not implemented in practice. Concerns about adherence with injectable therapy should not prevent use of these agents. Pharmacists should assess cancer patients for their risk of VTE and should advocate for optimal VTE pharmacotherapy as appropriate. If LMWH is the preferred agent, on the basis of the evidence, the pharmacist should educate the patients appropriately and work with the prescriber to ensure best care.
doi:10.3821/1913-701X-145.1.24
PMCID: PMC3567538  PMID: 23509484
16.  Venous Thromboembolism Prophylaxis among Medical Patients at US Hospitals 
Background
Chemoprophylaxis is recommended for medical patients at moderate to high risk of venous thromboembolism (VTE) and is now a requirement of the Joint Commission on Accreditation of Healthcare Organizations. To see who receives prophylaxis and how far hospitals will need to go to meet this requirement, we examined VTE prophylaxis patterns at US hospitals.
Methods
We conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in 2004–2005. We excluded patients on warfarin or with hospital stays of <2 days. VTE prophylaxis was assessed by billing codes for any heparin or compression device. We classified patient risk using a VTE risk prediction model.
Results
Of 351,535 patients included, 36% received prophylaxis by hospital day 2. Prophylaxis rates were highest among patients with certain VTE risk factors, including mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%), and prior VTE (44%). The median hospital rate was 31% (IQR 19% to 42%); only 3% of hospitals had rates >70%. Compared to patients at low risk of VTE (<0.05%), patients at high risk (>1.0%) were more likely to receive prophylaxis (52% vs. 34%, p < 0.001). Hospitals with high rates of prescribing for high-risk patients also had high rates for low-risk patients.
Conclusions
VTE prophylaxis rates at US hospitals are substantially below Joint Commission targets, even for patients at highest risk of VTE.
doi:10.1007/s11606-010-1296-y
PMCID: PMC2869415  PMID: 20352366
venous thromboembolism (VTE); hospital mortality; chemoprophylaxis
17.  Venous thromboembolism prophylaxis in hospitalized elderly patients: Time to consider a ‘MUST’ strategy 
Venous thromboembolism (VTE) is the commonest cause of preventable death in hospitalized patients. Elderly patients have higher risk of VTE because of the high prevalence of predisposing co-morbidities and acute illnesses. Clinical diagnosis of VTE in the elderly patient is particularly difficult and, as such, adequate VTE prophylaxis is of pivotal importance in reducing the mortality and morbidities of VTE. Omission of VTE prophylaxis is, however, very common despite continuous education. A simple way to overcome this problem is to implement universal VTE prophylaxis for all hospitalized elderly patients instead of selective prophylaxis for some patients only according to individual's risk of VTE. Although pharmacological VTE prophylaxis is effective for most patients, a high prevalence of renal impairment and drug interactions in the hospitalized elderly patients suggests that a multimodality approach may be more appropriate. Mechanical VTE prophylaxis, including calf and thigh compression devices and/or an inferior vena cava filter, are often underutilized in hospitalized elderly patients who are at high-risk of bleeding and VTE. Because pneumatic compression devices and thigh length stockings are virtually risk free, mechanical VTE prophylaxis may allow early or immediate implementation of VTE prophylaxis for all hospitalized elderly patients, regardless of their bleeding and VTE risk. Although the cost-effectiveness of this Multimodality Universal STat (‘MUST’) VTE prophylaxis approach for hospitalized elderly patients remains uncertain, this strategy appears to offer some advantages over the traditional ‘selective and single-modal’ VTE prophylaxis approach, which often becomes ‘hit or miss’ or not implemented promptly in many hospitalized elderly patients. A large clustered randomized controlled trial is, however, needed to assess whether early, multimodality, universal VTE prophylaxis can improve important clinical outcomes of hospitalized elderly patients.
doi:10.3724/SP.J.1263.2011.00114
PMCID: PMC3390075  PMID: 22783295
age; bundle of care; deep vein thrombosis; prevention; pulmonary embolism
18.  Adherence to local guidelines for venous thromboprophylaxis: a cross-sectional study of medical inpatients in Argentina 
Thrombosis Journal  2011;9:18.
Background
Venous thromboembolism prophylaxis has been shown to safely and cost-effectively reduce the incidence of thromboembolic events in medical inpatients. However, there is a gap between evidence and medical practice. The aim of this study was evaluate the appropriateness of prescribing venous thromboembolism prophylaxis in accordance with local recommendations for medical inpatients.
Methods
This cross-sectional study included 310 prescriptions of medical general-ward admitted patients of two university hospitals of Buenos Aires, Argentina.
Data was collected using filled-out prescriptions, medical records and interviews with the head attending physician. Information was gathered at different times during 16 days randomly selected over September 2007 and January 2008.
Results
One hundred eighty eight patients' prescriptions (60.6%) were appropriate according to the institutional guidelines. Inappropriateness was due to excessive (14.2%), insufficient (15.8%) and absent (9.4%) prescribing. According to the recommendations of the American College of Chest Physicians, 256 (82.6%) patients received appropriate prophylaxis. Twenty-nine patients (9.4%) were considered at low risk for thromboembolism and did not need pharmacologic or mechanical prophylaxis. One hundred three patients (33.2%) had at least one major risk factor for venous thromboembolism. Compliance with the institutional guidelines was more frequently in the case of high risk patients. Complex preventive measures and low risk patients were related to lower adherence to recommendations. In the multivariate analysis, predictors of inappropriateness were the requirement of a surgical procedure and absence of prophylaxis prescribing at admission. In contrast, patients with a diagnosis of gastrointestinal disorders had lower odds of inappropriateness than those with an infectious disease.
Conclusions
Most medical inpatients received some thromboprophylaxis measure, but the compliance with recommendations was less frequent. Efforts should be made to improve the appropriate prescription.
doi:10.1186/1477-9560-9-18
PMCID: PMC3286366  PMID: 22172213
19.  Cancer and venous thromboembolic disease: from molecular mechanisms to clinical management 
Current Oncology  2014;21(3):134-143.
Venous thromboembolism (vte) represents a major challenge in the management of patients with cancer. The malignant phenotype is associated with derangements in the coagulation cascade that can manifest as thrombosis, hemorrhage, or disseminated intravascular coagulation. The risk of vte is increased by a factor of approximately 6 in patients with cancer compared with non-cancer patients, and cancer patients account for approximately 20% of all newly diagnosed cases of vte. Postmortem studies have demonstrated rates of vte in patients with cancer to be as high as 50%. Despite that prevalence, vte prophylaxis is underused in hospitalized patients with cancer. Studies have demonstrated that hospitalized patients with cancer are less likely than their non-cancer counterparts to receive vte prophylaxis. Consensus guidelines address the aforementioned issues and emerging concepts in the area, including the use of risk-assessment models, biomarkers to identify patients at highest risk of vte, and use of anticoagulants as anticancer therapy. Despite those guidelines, a gulf exists between current recommendations and clinical practice; greater efforts are thus required to ensure effective implementation of strategies to reduce the incidence of vte in patients with cancer.
doi:10.3747/co.21.1864
PMCID: PMC4059798  PMID: 24940094
Venous thromboembolism
20.  An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding 
PLoS Medicine  2009;6(6):e1000098.
Using decision analysis, Henry Stelfox and colleagues estimate the cost-effectiveness of three venous thromboembolism prophylaxis strategies in patients with severe traumatic injuries who were also at risk for bleeding complications.
Background
Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding.
Methods and Findings
Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies—pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF)—in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis.
Conclusions
The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.
Please see later in the article for Editors' Summary
Editors' Summary
Background
For patients who have been seriously injured in an accident or a violent attack (trauma patients), venous thromboembolism (VTE)—the formation of blood clots that limit the flow of blood through the veins—is a frequent and potentially fatal complication. The commonest form of VTE is deep vein thrombosis (DVT). “Distal” DVTs (clots that form in deep veins below the knee) affect about half of patients with severe trauma; “proximal” DVTs (clots that form above the knee) develop in one in five trauma patients. DVTs cause pain and swelling in the affected leg and can leave patients with a painful condition called post-thrombotic syndrome. Worse still, part of the clot can break off and travel to the lungs where it can cause a life-threatening pulmonary embolism (PE). Distal DVTs rarely embolize but, if untreated, half of patients who present with a proximal DVT will develop a PE, and 2%–3% of them will die as a result.
Why Was This Study Done?
VTE is usually prevented by using heparin, a drug that stops blood clotting, but clinicians treating critically ill trauma patients have a dilemma. Many of these patients are at high risk of serious bleeding complications so cannot be given heparin to prevent VTE. Nonpharmacological ways to prevent VTE include the use of pneumatic compression devices to keep the blood moving in the legs (clots often form in patients confined to bed because of the sluggish blood flow in their legs), repeated screening for blood clots using Doppler ultrasound, and the insertion of a “vena cava filter” into the vein that takes blood from the legs to the heart. This last device catches blood clots before they reach the lungs but increases the risk of DVT. Unfortunately, no-one knows which VTE prevention strategy works best in trauma patients who cannot be given heparin. In this study, therefore, the researchers use decision analysis (the systematic evaluation of the most important factors affecting a decision) to estimate the costs and likely clinical outcomes of these strategies.
What Did the Researchers Do and Find?
The researchers used cost and clinical data from patients admitted to a Canadian trauma center with severe head/neck and/or abdomen/pelvis injuries (patients with a high risk of bleeding complications likely to make heparin therapy dangerous for up to two weeks after the injury) to construct a Markov decision analysis model. They then fed published data on the chances of patients developing DVT or PE, and on the effectiveness of the three VTE prevention strategies, into the model to obtain estimates of the costs and clinical outcomes of the strategies at 12 weeks after the injury and over the patients' lifetime. The estimated incidence of DVT at 12 weeks was 15% for the pneumatic compression device and Doppler ultrasound strategies, but 25% for the vena cava filter strategy. By contrast, the estimated incidence of PE was 2.9% with the pneumatic compression device, 1.5% with Doppler ultrasound, but only 0.3% with the vena cava filter. The expected mortality with all three strategies was similar. Finally, the estimated health care costs per patient at 12 weeks were Can$55,334 and Can$55,831 for the Doppler ultrasound and pneumatic compression device strategies, respectively, but Can$57,377 for the vena cava filter strategy; similar trends were seen for lifetime health care costs.
What Do These Findings Mean?
As with all mathematical models, these findings depend on the data fed into the model and on the assumptions included in it. For example, because data from one Canadian trauma unit were used to construct the model, these findings may not be generalizable. Nevertheless, these findings suggest that, although VTE is common among patients with severe injuries, PE is not a major cause of death among these patients. They also suggest that the use of vena cava filters for VTE prevention in patients who cannot receive heparin should not be routinely used because it is expensive and increases the risk of DVT. Finally, these results suggest that, compared with the other strategies, serial Doppler ultrasound is associated with better clinical outcomes and lower costs.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000098.
The US National Heart Lung and Blood Institute provides information (including an animation) on deep vein thrombosis and pulmonary embolism
MedlinePlus provides links to more information about deep vein thrombosis and pulmonary embolism (in several languages)
The UK National Health Service Choices Web site has information on deep vein thrombosis and on embolism (in English and Spanish)
The Eastern Association for the Surgery of Trauma working group document Practice Management Guidelines for the Management of Venous Thromboembolism in Trauma Patients can be downloaded from the Internet
doi:10.1371/journal.pmed.1000098
PMCID: PMC2695771  PMID: 19554085
21.  Venous thromboembolism in patients with inflammatory bowel disease: Focus on prevention and treatment 
Inflammatory bowel disease (IBD) patients have an increased risk of venous thromboembolism (VTE), which represents a significant cause of morbidity and mortality. The most common sites of VTE in IBD patients are the deep veins of the legs and pulmonary system, followed by the portal and mesenteric veins. However, other sites may also be involved, such as the cerebrovascular and retinal veins. The aetiology of VTE is multifactorial, including both inherited and acquired risk factors that, when simultaneously present, multiply the risk to the patient. VTE prevention involves correcting modifiable risk factors, such as disease activity, vitamin deficiency, dehydration and prolonged immobilisation. The role of mechanical and pharmacological prophylaxis against VTE using anticoagulants is also crucial. However, although guidelines recommend thromboprophylaxis for IBD patients, this method is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in these patients. Further efforts are required to increase the rate of pharmacological prevention of VTE in IBD patients to avoid preventable morbidity and mortality.
doi:10.3748/wjg.v20.i12.3173
PMCID: PMC3964389  PMID: 24695669
Inflammatory bowel disease; Venous thromboembolism; Thromboembolic prophylaxis; Anticoagulants; Unfractionated heparin; Low molecular weight heparin
22.  The Efficacy and Safety of Rivaroxaban for Venous Thromboembolism Prophylaxis after Total Hip and Total Knee Arthroplasty 
Thrombosis  2013;2013:762310.
Venous thromboembolism (VTE) is a common complication after total hip and total knee arthroplasty. Currently used methods of VTE prophylaxis after these procedures have important limitations, including parenteral administration, and unpredictable plasma levels requiring frequent monitoring and dose adjustment leading to decreased patient compliance with recommended guidelines. New oral anticoagulants have been demonstrated in clinical trials to be equally efficacious to enoxaparin and allow for fixed dosing without the need for monitoring. Rivaroxaban is one of the new oral anticoagulants and is a direct factor Xa inhibitor that has demonstrated superior efficacy to that of enoxaparin. However, the data also suggest that rivaroxaban has an increased risk of bleeding compared to enoxaparin. This paper reviews the available data on the efficacy and safety of rivaroxaban for VTE prophylaxis after total hip and total knee arthroplasty.
doi:10.1155/2013/762310
PMCID: PMC3595683  PMID: 23533746
23.  Prevention and treatment of venous thromboembolism in the elderly patient 
Clinical Interventions in Aging  2007;2(2):237-246.
Venous thromboembolism (VTE) is a common complication among hospitalized patients. Pharmacological thromboprophylaxis has emerged as the cornerstone for VTE prevention. As trials on thromboprophylaxis in medical patients have proven the efficacy of both low-molecular-weight heparins (LMWHs) and unfractionated heparin (UFH), all acutely medical ill patients should be considered for pharmacological thromboprophylaxis. Unlike in the surgical setting where the risk of associated VTE attributable to surgery is well recognized, and where widespread use of pharmacological thromboprophylaxis and early mobilization has resulted in significant reductions in the risk of VTE, appropriate VTE prophylaxis is under-used in medical patients. Many reasons for this under-use have been identified, including low perceived risk of VTE in medical patients, absence of optimal tools for risk assessment, heterogeneity of patients and their diseases, and fear of bleeding complications. A consistent group among hospitalized medical patients is composed of elderly patients with impaired renal function, a condition potentially associated with bleeding. How these patients should be managed is discussed in this review. Particular attention is devoted to LMWHs and fondaparinux and to measures to improve the safety and the efficacy of their use.
PMCID: PMC2684509  PMID: 18044139
venous thromboembolism; elderly patient; fondaparinux
24.  Venous thromboembolism risk & prophylaxis in the acute hospital care setting (ENDORSE), a multinational cross-sectional study: Results from the Indian subset data 
Background & objectives:
Venous thromboembolism (VTE) is a major health problem with substantial morbidity and mortality. It is often underdiagnosed due to lack of information on VTE risk and prophylaxis. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study aimed to assess the prevalence of VTE risk in acute hospital care setting and proportion of at-risk patients receiving effective prophylaxis. We present here the risk factor profile and prophylaxis pattern of hospitalized patients who participated in ENDORSE study in India.
Methods:
In this cross-sectional study in India, all patients (surgical >18 yr, medical >40 yr) from 10 hospitals were retrospectively studied. Demographics, VTE risk factors and prophylaxis patterns were assessed according to the 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines.
Results:
We recruited 2058 patients (1110 surgical, 948 medical) from 10 randomly selected hospitals in India between August 2006 and January 2007. According to the ACCP criteria, 1104 (53.6%) patients [surgical 680 (61.3%), medical 424 (44.7%)] were at-risk for VTE. Chronic pulmonary disease/heart failure and complete immobilization were the most common risk factors before and during hospitalization, respectively. In India, 16.3 per cent surgical and 19.1 per cent medical at-risk patients received ACCP-recommended thromboprophylaxis.
Interpretation & conclusions:
Despite a similar proportion of at-risk hospitalized patients in India and other participating countries, there was major underutilization of prophylaxis in India. It necessitates increasing awareness about VTE risk and ensuring appropriate thromboprophylaxis.
PMCID: PMC3461719  PMID: 22885265
India; thromboprophylaxis; venous thromboembolism (VTE); VTE risk
25.  Improving adherence to venous thromoembolism prophylaxis using multiple interventions 
Annals of Thoracic Medicine  2011;6(2):82-84.
OBJECTIVE:
In hospital, deep vein thrombosis (DVT) increases the morbidity and mortality in patients with acute medical illness. DVT prophylaxis is well known to be effective in preventing venous thromoembolism (VTE). However, its use remains suboptimal. The objective of this study was to evaluate the impact of quality improvement project on adherence with VTE prophylaxis guidelines and on the incidence of hospital-acquired VTEs in medical patients.
METHODS:
The study was conducted at Saudi Aramco Medical Services Organization from June 2008 to August 2009. Quality improvement strategies included education of physicians, the development of a protocol, and weekly monitoring of compliance with the recommendations for VTE prophylaxis as included in the multidisciplinary rounds. A feedback was provided whenever a deviation from the protocol occurs.
RESULTS:
During the study period, a total of 560 general internal medicine patients met the criteria for VTE prophylaxis. Of those, 513 (91%) patients actually received the recommended VTE prophylaxis. The weekly compliance rate in the initial stage of the intervention was 63% (14 of 22) and increased to an overall rate of 100% (39 of 39) (P = 0.002). Hospital-acquired DVT rate was 0.8 per 1000 discharges in the preintervention period and 0.5 per 1000 discharges in the postintervention period, P = 0.51. However, there was a significant increase in the time-free period of the VTE and we had 11 months with no single DVT.
CONCLUSION:
In this study, the use of multiple interventions increased VTE prophylaxis compliance rate.
doi:10.4103/1817-1737.78425
PMCID: PMC3081561  PMID: 21572697
Deep vein thrombosis; quality improvement; thromboprophylaxis; underutilization; venous thromboembolism

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