Variation in physician deep vein thrombosis prophylaxis attitudes and practices at an academic tertiary care center.

J Thromb Thrombolysis. 2010 Feb 20;

Authors: Galbraith EM, Vautaw BM, Grzybowski M, Henke PK, Wakefield TW, Froehlich JB

Background Deep vein thrombosis (DVT) remains a major cause of in-hospital morbidity and mortality. Effective DVT prophylaxis is available but underutilized. We sought to describe physician understanding of DVT epidemiology and prophylaxis practices. Methods All medical and surgical residents, and hospitalist attendings were invited to participate in an on-line survey. Physicians were queried about DVT epidemiology, risk factors, prophylaxis practices, and complications. Means and standard deviations were calculated for ordinal responses. chi(2) was used for dichotomous variables. Results Of 281 doctors emailed, 69/160 (43%) medical residents, 26/72 (36%) surgical residents, and 21/49 (43%) hospitalist attendings participated. All three overestimated DVT incidence and morbidity. Surgical residents listed paralysis as high risk and minor surgery as a low/no risk factor. Medical residents thought heart failure and varicose veins were low/no risk for developing DVT. Regarding prophylaxis, surgical residents did not identify ambulation as a prophylactic measure, and were more likely to use SCDs, compression stockings, and enoxaparin, while medical residents and hospitalist attendings prescribed unfractionated heparin most frequently. Medical residents reported that they would hold anticoagulants for comorbidities most frequently, but all 3 groups agreed that anticoagulant prophylaxis would not significantly increase bleeding risks. Conclusions Perceptions of DVT risk factors and prophylaxis practices vary by both physician specialty and attending/resident status. Prophylaxis practice differences may result from these perceptions.

PMID: 20174856 [PubMed - as supplied by publisher]

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Comparison of pain and ecchymosis with low-molecular-weight heparin vs. unfractionated heparin in patients requiring bridging anticoagulation after warfarin interruption: a randomized trial.

J Thromb Thrombolysis. 2009 Oct;28(3):266-8

Authors: Jamula E, Woods K, Verhovsek M, Douketis JD, McDonald E

BACKGROUND: Subcutaneous (SC) low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) are safe and efficacious for bridging anticoagulation after warfarin interruption. Although LMWH and UFH are self-administered by >90% of patients, factors that may be important to patients such as differences in pain and ecchymosis have not been explored. METHODS: We randomized 24 patients to receive SC LMWH or SC UFH twice-daily during the perioperative period. Injection associated pain was recorded using a visual analogue scale and area of ecchymosis was measured by digital photography of the injection site on the day of the procedure. RESULTS: The area of ecchymosis was 2-fold higher with UFH than LMWH (19.4 cm(2) vs. 8.98 cm(2); P = 0.33) and pain was similar with both treatments (115 mm vs. 171 mm; P = 0.25), though neither finding attained statistical significance. CONCLUSIONS: This exploratory study was underpowered to detect differences between the groups. Further studies are needed to reliably compare pain and ecchymosis in LMWH vs. UFH.

PMID: 19219405 [PubMed - indexed for MEDLINE]

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Improving adjunctive treatment in pulmonary embolism and fibrinolytic therapy. The role of enoxaparin and weight-adjusted unfractionated heparin.

J Thromb Thrombolysis. 2009 Feb;27(2):154-62

Authors: Jerjes-Sánchez C, Villarreal-Umaña S, Ramírez-Rivera A, Garcia-Sosa A, Miguel-Canseco L, Archondo T, Reyes E, Garza A, Arriaga R, Castillo F, Jasso O, Garcia H, Bermudez M, Hernandez JM, Garcia J, Martinez P, Rangel F, Gutierrez J, Comparan-Nuñez A

AIM: The role of enoxaparin and weight-adjusted unfractionated heparin (UH) as adjunct to fibrinolytic therapy in pulmonary embolism is unknown. METHODS: In a prospective, open-label, controlled multicenter trial, 80 patients with high-risk pulmonary embolism were enrolled. Forty patients received alteplase infusion plus weight-adjusted UH (24-48 h) and then enoxaparin (7 days). In control group, UH standard regimen was used. There were not differences on pulmonary embolism extension, (P 0.63) and right ventricular hypokinesis (P 0.07) in both groups. In terms of in-hospital survival (P 0.009), escalation treatment (P < 0.001) and in-hospital stay (P < 0.001) study group had better outcome than opposite group. In a 30 (P < 0.001) and 90 (P < 0.001) days follow-up pulmonary perfusion was improved in patients who received enoxaparin versus heparin alone without increasing major bleeding complications. CONCLUSION: Enoxaparin and weight-adjusted intravenous UH as adjunct to 1-h alteplase infusion improve in-hospital and follow-up outcome compared to heparin alone in high-risk PE.

PMID: 18204981 [PubMed - indexed for MEDLINE]

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Antithrombotic therapy in atrial fibrillation: guidelines translated for the clinician.

J Thromb Thrombolysis. 2008 Dec;26(3):167-74

Authors: Lopes RD, Piccini JP, Hylek EM, Granger CB, Alexander JH

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice, accounting for approximately one-third of hospitalizations for cardiac rhythm disturbances. The highest incidence of AF is in patients 70-80 years old and other high-risk populations. Although the diagnosis of AF is usually straightforward, effective treatment strategies are less well implemented. This is particularly true for antithrombotic therapy, which is very effective at preventing thromboembolic complications of AF. Stroke is the most significant morbidity in AF patients. The yearly risk of stroke increases from 1.5% for AF patients aged 50-59 to 23% for those aged 80-89. Ischemic strokes secondary to AF carry twice the risk of death when compared with strokes from other causes. We provide a practical and useful review of the most recent American College of Cardiology/American Heart Association/European Society of Cardiology guidelines-based care and future directions of antithrombotic therapy for patients with AF.

PMID: 18807225 [PubMed - indexed for MEDLINE]

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Underutilization of venous thromboemoblism prophylaxis in medical patients in a tertiary care center.

J Thromb Thrombolysis. 2008 Oct;26(2):138-41

Authors: Masroujeh R, Shamseddeen W, Isma’eel H, Otrock ZK, Khalil IM, Taher A

BACKGROUND: New recommendations concerning the use of prophylactic anticoagulation for medically ill patients have been in use for some time now. This study aims at assessing how much house-staff in a tertiary care setting are implementing these new recommendations in the hope that through quantitative analysis of the deficiency we would be able to identify areas of weakness. METHODS: About 250 patients were randomly selected from all patients admitted to the American University of Beirut Medical Center (AUBMC) during the year 2005 and stayed more than 48 h. The risk factor profiles, contraindications to thromboprophylaxis, if present, and whether these patients received the appropriate VTE pharmacologic prophylaxis during their stay in hospital were recorded. RESULTS: About 139 patients were found to have two or more risk factors, with no absolute contraindications. About 37 patients (26.6%) received VTE prophylaxis. Upon reviewing the risk factors profile, the majority of patients (71.3%) were found to have 2-4 risk factors. Among risk factors studied, age > 40 years, admission to ICU, prior VTE, chronic lung disease, infection, respiratory failure, and central venous catheter were significantly associated with receiving prophylaxis. CONCLUSIONS: VTE prophylaxis is underutilized at AUBMC, a tertiary care teaching hospital in the Middle East. Critical care patients were being acceptably anti-coagulated, whereas cancer patients are doing the worst.

PMID: 17701104 [PubMed - indexed for MEDLINE]

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Chronic obstructive pulmonary disease and deep vein thrombosis: a prevalent combination.

J Thromb Thrombolysis. 2008 Aug;26(1):35-40

Authors: Shetty R, Seddighzadeh A, Piazza G, Goldhaber SZ

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for venous thromboembolism (VTE). We analyzed a large US deep vein thrombosis (DVT) registry to explore the profile of patients with COPD and VTE. METHODS: Demographics, symptoms, risk factors, prophylaxis, and initial management of 668 (12%) patients with COPD were compared to 3,907 patients without COPD from a prospective registry of 5,451 consecutive patients with ultrasound-confirmed DVT at 183 institutions in the United States. RESULTS: COPD patients with DVT were older (median 72.5 years vs. 68.0 years, P < 0.0001) and more likely to be male (52.3% vs. 44.8%, P = 0.0004). They were more likely to be inpatients at the time of diagnosis of DVT (62.0% vs. 51.9%, P < 0.0001). COPD patients were more likely to be admitted to the intensive care unit (ICU) (27.7% vs.19.8%, P = 0.0003), more likely to require mechanical ventilation (23.2% vs. 13.6%, P < 0.0001), and more likely to receive inferior vena caval (IVC) filters (19.1% vs. 15.1%, P = 0.009). COPD patients more often had concomitant pulmonary embolism (PE) (22.8% vs.17.8%, P = 0.005) as well as concomitant congestive heart failure (29.5% vs. 12.5%, P < 0.0001). CONCLUSIONS: DVT patients with COPD have a greater medical acuity than other DVT patients. This results in more frequent IVC filter insertion.

PMID: 17940729 [PubMed - indexed for MEDLINE]

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Frequency of thromboprophylaxis and incidence of in-hospital venous thromboembolism in a cohort of emergency department patients.

J Thromb Thrombolysis. 2008 Apr;25(2):160-4

Authors: Jones AE, Fordham Z, Yiannibas V, Johnson CL, Kline JA

OBJECTIVE: Prior work suggests that in-hospital pulmonary and venous thromboembolism (VTE) could be decreased if the rate of prophylaxis for VTE in high-risk patients were increased at the time of admission. Our objective was to quantify the rate of thromboprophylaxis and incidence of in-hospital VTE, based upon risk of VTE, in a cohort of patients admitted through the emergency department (ED). METHODS: We performed a prospective cohort study at an urban ED with >100,000 visits. All medical patients >17 years admitted from the ED were prospectively identified on a random sample of days for one year. Using a structured data form we collected each patient's risk factors for VTE, and prophylaxis measures. We computed a validated risk score of each patient, with a score >or=4 high-risk (HR) and a score <4 low risk (LR). The main outcome was VTE during the hospitalization, diagnosed after admission from ED. RESULTS: Of 4732 patients, VTE was diagnosed during hospitalization in 44 (0.9%). 437 (9%) patients were HR for VTE and HR patients had significantly higher frequency of VTE vs. LR patients, 1.8 vs. 0.8% (95% CI for difference of 1% = 0.1-3%). Only 36% of HR patients received thromboprophylaxis. There were no significant differences in the frequency of observed inpatient VTE events between patients who were prescribed prophylaxis compared with those who were not prescribed prophylaxis in either risk group. CONCLUSION: These data suggest only a modest opportunity for ED-based policy for thromboprophylaxis in admitted medical patients.

PMID: 17577627 [PubMed - indexed for MEDLINE]

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Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study.

J Thromb Thrombolysis. 2008 Apr;25(2):146-50

Authors: Baroletti S, Munz K, Sonis J, Fanikos J, Fiumara K, Paterno M, Goldhaber SZ

BACKGROUND: Despite existing consensus guidelines, venous thromboembolism (VTE) prophylaxis is underused in high-risk hospitalized patients. The present study evaluated the effects of an electronic alert to the responsible physician in a cohort of hospitalized high-risk patients not receiving VTE prophylaxis. METHODS: The absence of VTE prophylaxis orders in hospitalized patients at high-risk for VTE triggered an electronic alert to the responsible physician. We studied a cohort of 866 patients whose physicians were alerted that their patients were at high-risk but receiving no VTE prophylaxis. The electronic alert recommended that the responsible physician order preventive measures. We followed each patient for 90 days to determine whether imaging-confirmed symptomatic VTE occurred. RESULTS: 9,527 patients were identified as high-risk for VTE. 9% (866) were not receiving prophylaxis, compared with 18% in the intervention arm of a previous randomized trial (P < 0.001). In our current cohort study, 82% (713) of patients were Medical Service patients. Physician response to alerts resulted in prophylactic measures for 37.7% of those alerted. Symptomatic VTE at 90 days occurred in 5.1% of patients in the present cohort group. CONCLUSION: Implementation of a computer alert program increased prophylaxis rates. However, the majority of alerted physicians in the cohort study did not order VTE prophylaxis despite the alerts. Therefore, novel strategies must be employed to further improve the use of VTE prophylaxis in hospitalized high-risk patients, especially in Medical Service patients.

PMID: 18026689 [PubMed - indexed for MEDLINE]

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Establishing an inpatient anticoagulation service: a step by step review.

J Thromb Thrombolysis. 2008 Feb;25(1):67-71

Authors: Viercinski J, Thomson L, Wilson J, Merli GJ

Inpatient anticoagulation services can reduce medication errors, reduce hospital costs, and improve patient care. However, before a hospital establishes an inpatient anticoagulation service, it is important to conduct a thoughtful, systematic review of the institution. Two factors that can determine the need for an inpatient anticoagulation service are the number of adverse drug events and the extent of medical-legal liability at the institution. Establishing an inpatient service that reduces these problems can justify the cost of the program. In addition to these factors, the institution’s infrastructure and the scope of services to be provided should be evaluated, and parameters should be created to measure the clinical and financial impact of the inpatient anticoagulation service. Numerous publications in the literature have supported the need and positive impact of inpatient anticoagulation services on hospital costs and patient care. The size and scope of the service should be based upon the needs, experiences and resources of a specific institution.

PMID: 17906914 [PubMed - indexed for MEDLINE]

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