High incidence of venous thromboembolism despite electronic alerts for thromboprophylaxis in hospitalised cancer patients

Summary

Many cancer patients are at high risk of venous thromboembolism (VTE) during hospitalisation; nevertheless, thromboprophylaxis is frequently underused. Electronic alerts (e-alerts) have been associated with improvement in thromboprophylaxis use and a reduction of the incidence of VTE, both during hospitalisation and after discharge, particularly in the medical setting. However, there are no data regarding the benefit of this tool in cancer patients. Our aim was to evaluate the impact of a computer-alert system for VTE prevention in patients with cancer, particularly in those admitted to the Oncology/Haematology ward, comparing the results with the rest of inpatients at a university teaching hospital. The study included 32,167 adult patients hospitalised during the first semesters of years 2006 to 2010, 9,265 (28.8%) with an active malignancy. Appropriate prophylaxis in medical patients, significantly increased over time (from 40% in 2006 to 57% in 2010) and was maintained over 80% in surgical patients. However, while e-alerts were associated with a reduction of the incidence of VTE during hospitalisation in patients without cancer (odds ratio [OR] 0.31; 95% confidence interval [CI], 0.15–0.64), the impact was modest in cancer patients (OR 0.89; 95% CI, 0.42–1.86) and no benefit was observed in patients admitted to the Oncology/Haematology Departments (OR 1.11; 95% CI, 0.45–2.73). Interestingly, 60% of VTE episodes in cancer patients during recent years developed despite appropriate prophylaxis. Contrary to the impact on hospitalised patients without cancer, implementation of e-alerts for VTE risk did not prevent VTE effectively among those with malignancies.

Keywords

Venous thromboembolism - cancer - hospitalised patients - electronic alerts - prophylaxis

• References

• 1 Cohen AT, Agnelli G, Anderson FA. et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-764.
• 2 Dunn AS, Brenner A, Halm EA. The magnitude of an iatrogenic disorder: a systematic review of the incidence of venous thromboembolism for general medical inpatients. Thromb Haemost 2006; 95: 758-762.
• 3 Sousou T, Khorana AA. New insights into cancer-associated thrombosis. Arterioscler Thromb Vasc Biol 2009; 29: 316-320.
• 4 Khorana AA, Francis CW, Culakova E. et al. Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients. Cancer 2007; 110: 2339-2346.
• 5 Khorana AA, Francis CW, Culakova E. et al. Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J Thromb Haemost 2007; 05: 632-634.
• 6 Chew HK, Wun T, Harvey D. et al. Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med 2006; 166: 458-464.
• 7 Dentali F, Douketis JD, Gianni M. et al. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146: 278-288.
• 8 Lloyd NS, Douketis JD, Moinuddin I. et al. Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis. J Thromb Haemost 2008; 06: 405-414.
• 9 Kahn SR, Lim W, Dunn AS. et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e195S-226S.
• 10 Tapson VF, Decousus H, Pini M. et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007; 132: 936-945.
• 11 Cohen AT, Tapson VF, Bergmann JF. et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387-394.
• 12 Amin AN, Lin J, Thompson S. et al. Real-world rates of in-hospital and postdis-charge deep-vein thrombosis and pulmonary embolism in at-risk medical patients in the United States. Clin Appl Thromb Hemost 2011; 17: 611-619.
• 13 Kucher N, Koo S, Quiroz R. et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005; 352: 969-977.
• 14 Lecumberri R, Marqués M, Díaz-Navarlaz MT. et al. Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients. Thromb Haemost 2008; 100: 699-704.
• 15 Kucher N, Puck M, Blaser J. et al. Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patients. J Thromb Haemost 2009; 07 1 291-296.
• 16 Beeler PE, Kucher N, Blaser J. Sustained impact of electronic alerts on rate of prophylaxis against venous thromboembolism. Thromb Haemost 2011; 106: 734-738.
• 17 Lecumberri R, Panizo E, Gomez-Guiu A. et al. Economic impact of an electronic alert system to prevent venous thromboembolism in hospitalised patients. J Thromb Haemost 2011; 09: 1108-1115.
• 18 Geerts WH, Pineo GF, Heit JA. et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (Suppl. 03) 338S-400S.
• 19 Alonso C, Medrano FJ, Romero A. et al. Guía PRETEMED 2003. Guía de pro-filaxis de enfermedad tromboembólica en patología médica. SADEMI, Córdoba; 2003. ISBN: 84-699-8538-8 (84-699-8537-X).
• 20 Ministerio de Sanidad, Servicios Sociales e Igualdad. Clasificación internacional de Enfermedades, 9ª revisión, Modificación Clínica. Madrid. Ediciones 2004, 2006, 2008, 2010.
• 21 3M Health Information Systems 575 West Murray Boulevard Salt Lake City. UT 84123, USA: Available at: www.3Mhis.com.
• 22 Amin AN, Deitelzweig SB. Optimising the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement. Jt Comm J Qual Patient Saf 2009; 35: 558-564.
• 23 Monreal M, Falgá C, Valdés M. et al. Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry. J Thromb Haemost 2006; 04: 1950-1956.
• 24 Fiumara K, Piovella C, Hurwitz S. et al. Multi-screen electronic alerts to augment venous thromboembolism prophylaxis. Thromb Haemost 2010; 103: 312-317.
• 25 Kucher N, Spirk D, Baumgartner I. et al. Lack of prophylaxis before the onset of acute venous thromboembolism among hospitalized cancer patients: the SWIss Venous ThromboEmbolism Registry (SWIVTER). Ann Oncol 2010; 21: 931-935.
• 26 Agnelli G, George DJ, Kakkar AK. et al. Semuloparin for thromboprophylaxis in patients receiving chemotherapy for cancer. N Engl J Med 2012; 366: 601-609.
• 27 Hull RD, Schellong SM, Tapson VF. et al. Extended-duration venous throm-boembolism prophylaxis in acutely ill medical patients with recently reduced mobility: a randomized trial. Ann Intern Med 2010; 153: 8-18.
• 28 Leizorovicz A, Cohen AT, Turpie AG. et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004; 110: 874-879.
• 29 Ageno W. Do medical patients need to receive pharmacologic prophylaxis for the prevention of venous thromboembolism?. Intern Emerg Med 2012; 07 (Suppl. 03) S189-192.
• 30 Prandoni P, Lensing AW, Piccioli A. et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002; 100: 3484-3488.
• 31 Imberti D, Prisco D. Venous thromboembolism prophylaxis in medical patients: future perspectives. Thromb Res 2005; 116: 365-375.
• 32 Lyman GH, Khorana AA, Falanga A. et al. American Society of Clinical Oncology. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25: 5490-5505.
• 33 Schulman S. Thromboprophylaxis in medical patients - why not for all?. Patho-physiol Haemost Thromb 2006; 35: 141-145.
• 34 Decousus H, Tapson VF, Bergmann JF. et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 2011; 139: 69-79.
• 35 Goldhaber SZ. Outpatient venous thromboembolism: the importance of optimum prophylaxis. Nat Clin Pract Cardiovasc Med 2008; 05: 12-13.