1. Merli, Geno J. MD, FACP, FHM

Article Content

Deep vein thrombosis (DVT) is a major clinical problem in the United States, with an estimated incidence of between 500,000 and 2 million cases per year.1 The most serious complication of DVT is pulmonary embolism (PE), which accounts for approximately 300,000 deaths per year and 10% of hospital deaths.1,2 These 2 conditions comprise venous thromboembolism (VTE), which is a major and often unrecognized cause of morbidity and mortality in hospitalized patients.3 Using the International Classification of Diseases, Ninth Edition, Clinical Modification code for DVT, approximately 250,000 hospital admissions per year for this diagnosis have been identified, with an estimated length of stay between 24 hours and 7 days.4


In a retrospective study of nearly 7.5 million patients in the United States, the risk of postoperative VTE was 9.3 per 1,000 discharges and was associated with significant increases in both the length of hospital stay (mean 5.4 days) and mortality (6.6%) (P < .001 for both).3 And the clinical burden of VTE in the hospitalized acutely ill medical patients is also substantial, with nearly 8 million medical discharges considered to be specifically at risk of VTE during 2003.2 Thus, to minimize the morbidity and mortality associated with this condition, it is important to identify the patient at risk and develop management strategies not only to treat VTE when diagnosed but also prevent the disease. For patients not assessed for risk or provided with thromboprophylaxis, VTE can develop as a consequence of these omissions. The purpose of this article is to introduce the topic of VTE and the subsequent articles that are part of this supplement. In the first article of this supplement, Mason5 further discusses the incidence of VTE and overall risk assessment of patients.


Management Strategies for Preventing/Treating VTE

The timely diagnosis and treatment of VTE are an important part of the management of those patients who develop VTE sequelae either from the lack of prophylaxis or from failure of the prophylaxis itself. Despite the availability of effective thromboprophylaxis agents and evidence-based management guidelines, the use of prophylaxis and the appropriate use of therapeutic anticoagulation remain a national issue.6,7 Randomized, prospective clinical studies have shown that appropriate thromboprophylaxis can significantly reduce the risk of VTE and mortality.6,7 The standard of care for VTE is continuous infusion unfractionated heparin or subcutaneous low-molecular weight heparin followed by warfarin as secondary prevention of VTE. The goals of therapy for VTE include the prevention of thrombus propagation, embolization, and early and late thrombus recurrence. Proper anticoagulation after the confirmation of diagnosis is the first critical step in the effective treatment of VTE. The second step of therapy involves the maintenance of adequate anticoagulation to prevent the development of recurrent thromboembolism. The most effective approach in managing this patient population is the use of protocols to ensure appropriate diagnostic assessment and the achievement of target anticoagulation goals. In the second article of this supplement, Long8 provides an in-depth discussion surrounding pharmacologic and nonpharmacologic interventions of VTE.


Barriers to Effective Management of VTE

Evidence-based guidelines for VTE prophylaxis have been available for many years and are regularly updated as results from newer clinical studies regarding the efficacy and safety of different treatment regimens are completed and published.6,7 But despite the evidence of effective thromboprophylaxis and the widespread dissemination of these guidelines through education initiatives, prophylaxis is often underused or inappropriately prescribed.1,8-10 For example, in a large, cross-sectional, observational study, only 71% of at-risk surgical patients and 48% of at-risk medical patients received prophylaxis in accordance with guidelines from the American College of Chest Physicians (ACCP).6,7 In addition, a survey of 246 physicians revealed that only 54% reported that they used institutional or professional society guidelines.11


Reasons given for contributing to suboptimal prophylaxis practices include lack of familiarity with or detailed knowledge of VTE guidelines, and some physicians may underestimate the levels of VTE risk in their patients.11 Because most VTE events occur in the first 3 months after discharge rather than during hospital stay, this delay in response may lead the practitioner to conclude that "VTE is not common in our practice." Furthermore, asymptomatic VTE is often thought not to be clinically relevant, despite the evidence that asymptomatic proximal DVT is associated with increased mortality (P < .0001 vs no DVT).12


Another barrier responsible for poor adherence with current guidelines is overestimating the risk of bleeding with pharmacologic interventions.11 However, studies have shown that prophylactic doses of unfractionated heparin and low-molecular weight heparin are not associated with significantly increased risk of clinically relevant bleeding.6,7,13 All these factors may discourage the adoption and implementation of performance measures, and therefore, strategies are required to overcome these barriers and close the gap between clinical guidelines and clinical practice. If implemented, both DVT and PE are preventable complications of both medically ill and surgical patients in the hospitalized setting. In the third article of this supplement, Nelson-Worel14 provides further insight into factors that impact improvement in compliance toward treatment guidelines and performance measures.


Improving Adherence to VTE Treatment Guidelines

Improving adherence of healthcare practitioners is a complex task. Successful programs rely upon both improvement in thrombotic risk assessment methods and facilitating appropriate prescribing of prophylaxis. Interdisciplinary strategies involving risk assessment models, educational programs, electronic reminders, and audit and feedback have shown the most potential to improve compliance with guidelines.15


To raise the bar, several US organizations have developed quality improvement initiatives that will be used in conjunction with the abovementioned strategies to close the gap between guideline recommendations and clinical practice and thus reduce VTE-associated mortality and morbidity.16-19 These include the Agency for Healthcare Research and Quality, the National Quality Forum, the Center for Medicare and Medicaid Standards, and the Joint Commission. The Coalition to Prevent Deep-Vein Thrombosis, which is composed of multiple national organizations, has a focused goal to reduce the immediate and long-term dangers of DVT and PE; to educate the public, healthcare professionals, and policy makers on risk factors, symptoms, and signs associated with DVT; and to identify evidence-based measures to prevent morbidity and mortality from DVT and PE.


For individual hospitals, the goal is to reduce the incidence of first episode DVT and PE and the incidence of hospital readmissions for these conditions through the use of evidence-based, guideline-mandated prophylaxis and treatments. And if performance measures are not met by hospitals, Medicare and Medicaid reimbursements to these institutions can be significantly reduced.


The most recent performance measures for DVT prophylaxis in surgical patients implemented by Surgical Care Improvement Project (SCIP) were instituted to give direction to hospital to reach this goal. These measures are as follows:18


* Recommended VTE prophylaxis is ordered for all surgery patients before the surgical procedure.


* Surgery patients receive appropriate VTE prophylaxis within 24 hours before surgical procedure.



Although there are no formal SCIP-like performance measures in place for hospitalized medical patients, ACCP treatment guidelines for VTE should be used to minimize morbidity and mortality in these individuals.6



Hospitals will need to implement institutional-wide policies for VTE prevention and use several quality improvement initiatives to overcome barriers and optimize prescribing practices. Currently, the SCIP performance measures are in place to address surgical patients, and ACCP treatment guidelines are in place for medical patients at risk of VTE.


Multiple, integrated, active strategies to raise awareness for appropriate VTE prophylaxis will involve hospital-wide education of all healthcare practitioners; risk assessment tools, electronic alerts, computerized decision support systems, together with audit and feedback mechanisms. These are all valuable tools that can be used to promote implementation of performance measures and drive improvement. With the above measures in place, DVT and PE can be prevented and effectively treated if and when this complication may occur.




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