More than half of all hospital patients are at risk of venous thromboembolism (VTE), and steps must be taken to ensure that these patients are given appropriate preventive treatment to reduce this risk (prophylaxis). These are the conclusions of authors of an Article published in this week's edition of The Lancet.
VTE is a common complication during and after hospitalisation for acute medical illness or surgery. One type of VTE - pulmonary embolism - accounts for 5-10% of deaths in hospitalised patients, making VTE the most common preventable cause of in-hospital death (VTE results in over 20 times more hospital deaths than MRSA).¹ A US government review comparing 79 hospital preventive strategies (including hand-washing, antibiotic prophylaxis and pressure care) has rated VTE prophylaxis as the single most important strategy, based on efficacy, safety and cost.¹ While guidelines for VTE prophylaxis have been available for over 15 years, such treatment remains underused, and the proportion of patients who should receive it globally remains unknown. Appropriate treatments include anticoagulant drugs such as heparins and warfarin and mechanical methods such as intermittent pneumatic compression and graduated compression stockings.
Dr Ander Cohen, Vascular Medicine, King's College London, UK, and Professor Ajay Kakkar, Barts and The London School of Medicine and Dentistry, London, UK, and colleagues did the ENDORSE* study, which was designed to assess the prevalence of VTE risk in the acute hospital care setting, and determine the proportion of at-risk patients who receive effective prophylaxis.
The study analysed all hospital inpatients aged 40 years or over admitted to a medical ward, or those aged 18 or over admitted to a surgical ward, in 358 hospitals across 32 countries** -- and assessed them for VTE risk on the basis of hospital chart review. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and determine whether patients were receiving recommended prophylaxis.***
The researchers found that of 68183 patients enrolled, 30827 (45%) were categorised as surgical, and 37356 (55%) as medical. Using ACCP criteria, 35329 patients (51.8%) were judged to be at risk for VTE, including 19842 (64.4%) of surgical patients and 15487 (41.5%) of medical patients. Of the surgical patients at risk, 11613 (58.5%) received ACCP-recommended VTE prophylaxis, compared with 6119 (39.5%) of at-risk medical patients.
The proportions of patients receiving ACCP recommended VTE prophylaxis varied widely across the 32 countries, but did not necessarily follow the high-middle-low income gradient. For example, for at-risk medical patients the three countries with the highest proportions receiving prophylaxis were Germany (70%), Spain (64%), and Colombia (64%). Those with the lowest were Bangladesh (3%), Thailand (4%), and Romania (18%). In this category, the USA scored 48% and the UK just 37%. For at-risk surgical patients, the best performing countries were again Germany (92%), Hungary (87%) and again Spain (82%); and the worst were again Bangladesh and Thailand (both 0.2%), and Pakistan (10%). The UK scored 74% and the USA 71%.****
The authors say: "The data gathered show that, worldwide, more than half of all hospitalised patients are at risk for VTE, and that surgical patients seem to be at higher risk than medical patients." And, most significantly, they add: "Furthermore, only half of at risk patients received an ACCP-recommended method of prophylaxis."
They conclude: "Hospital-wide strategies to assess patients' VTE risk should be implemented, together with measures that ensure that at-risk patients receive appropriate VTE prophylaxis."
In an accompanying Comment, Dr Walter Ageno and Dr Francesco Dentali, Department of Clinical Medicine, University of Insubria, Varese, Italy, say: "Work is needed to improve prevention of VTE in hospitalised patients. Local programmes, such as electronic alerts to encourage prophylaxis in daily clinical practice, are effective and should be promoted. However, before these tools can be globally and successfully implemented, the prevalence of hospitalised patients who are at high-risk for VTE must be better appreciated, and guidelines supporting the appropriate use of prophylactic strategies should be endorsed by all medical and surgical societies."
Notes to editors:
¹ These stats are not referred to in the paper; see Cohen AT, Agnelli G, Anderson Jr FA, et al. Venous thromboembolism in Europe: The number of VTE events and associated morbidity and mortality.
Thromb Haemost 2007; 98: 756-64 & MRSA data from National Office of Statistics (NAO). Deaths Available at www.statistics.gov.uk
*ENDORSE study = Epidemiological International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting
** The 32 countries: UK, US, Algeria, Australia, Bangladesh, Brazil, Bulgaria, Columbia, Czech Republic, Egypt, France, Germany, Greece, Hungary, India, Ireland, Kuwait, Mexico, Pakistan, Poland, Portugal, Romania, Russia, Saudi Arabia, Slovakia, Spain, Switzerland, Thailand, Tunisia, Turkey, United Arab Emirates, Venezuela
*** See ACCP table appendix at end of full article
****Country by country data available on p392 of full article
Dr Ander Cohen, Vascular Medicine, King's College London, UK, T) +44 (0) 7775 605930 E) alexander.cohen@kcl.ac.uk
For Professor Ajay Kakkar, Barts and The London School of Medicine and Dentistry, London, UK, please contact Alex Fernades, Senior Press Officer, T) +44 (0) 20 7882 7910 / +44 (0)7932 640759 E) a.kakkar@qmul.ac.uk
Dr Walter Ageno, Department of Clinical Medicine, University of Insubria, Varese, Italy T) +39-0332-278 831 E) agewal@yahoo.com
PDF OF ARTICLE: http://multimedia.thelancet.com/pdf/press/Thromboembolism.pdf
Journal
The Lancet