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DOI: 10.1160/TH14-06-0525
Predictors of thromboprophylaxis in hospitalised medical patients
Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE)Financial support: The study was funded by an unrestricted educational grant from the International Society on Thrombosis and Haemostasis (ISTH) 2007 Presidential Fund and Sanofi-Aventis (Suisse) SA, Vernier, Switzerland.
Publication History
Received:
17 June 2014
Accepted after major revision:
02 January 2014
Publication Date:
24 November 2017 (online)
summary
Both, underuse and overuse of thromboprophylaxis in hospitalised medical patients is common. We aimed to explore clinical factors associated with the use of pharmacological or mechanical thromboprophylaxis in acutely ill medical patients at high (Geneva Risk Score ≥ 3 points) vs low (Geneva Risk Score < 3 points) risk of venous thromboembolism. Overall, 1,478 hospitalised medical patients from eight large Swiss hospitals were enrolled in the prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study. The study is registered on ClinicalTrials. gov, number NCT01277536. Thromboprophylaxis increased stepwise with increasing Geneva Risk Score (p< 0.001). Among the 962 high-risk patients, 366 (38 %) received no thromboprophylaxis; cancer-associated thrombocytopenia (OR 4.78, 95 % CI 2.75–8.31, p< 0.001), active bleeding on admission (OR 2.88, 95 % CI 1.69–4.92, p< 0.001), and thrombocytopenia without cancer (OR 2.54, 95 % CI 1.31–4.95, p=0.006) were independently associated with the absence of prophylaxis. The use of thromboprophylaxis declined with increasing severity of thrombocytopenia (p=0.001). Among the 516 low-risk patients, 245 (48 %) received thromboprophylaxis; none of the investigated clinical factors predicted its use. In conclusion, in acutely ill medical patients, bleeding and thrombocytopenia were the most important factors for the absence of thromboprophylaxis among highrisk patients. The use of thromboprophylaxis among low-risk patients was inconsistent, without clearly identifiable predictors, and should be addressed in further research.
* Both authors contributed equally.
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References
- 1 Kishimoto M, Lim HY, Tokuda Y. et al. Prevalence of venous thromboembolism at a teaching hospital in Okinawa, Japan. Thromb Haemost 2005; 93: 876-879.
- 2 Tapson VF, Decousus H, Pini M. et al. Venous thromboembolism prophylaxis in acutely ill hospitalised medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007; 132: 936-945.
- 3 Samama MM, Cohen AT, Darmon JY. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999; 341: 793-800.
- 4 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.
- 5 Cohen AT, Davidson BL, Gallus AS. et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. Br Med J 2006; 332: 325-329.
- 6 Dentali F, Douketis JD, Gianni M. et al. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalised medical patients. Ann Intern Med 2007; 146: 278-288.
- 7 Wein L, Wein S, Haas SJ. et al. Pharmacological venous thromboembolism prophylaxis in hospitalised medical patients: a meta-analysis of randomized controlled trials. Arch Intern Med 2007; 167: 1476-1486.
- 8 Vardi M, Steinberg M, Haran M. et al. Benefits versus risks of pharmacological prophylaxis to prevent symptomatic venous thromboembolism in unselected medical patients revisited. Meta-analysis of the medical literature. J Thromb Thrombolysis 2012; 34: 11-19.
- 9 Geerts WH, Bergqvist D, Pineo GF. et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) 381S-453S.
- 10 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-e226S.
- 11 Hayoz D, Kohler HP, Spahn DR. et al. 9 ACCP Guidelines on Antithrombotic Therapy kommentiert von Schweizer Experten. Schweiz Med Forum 2013; 13: 619-620.
- 12 Chopard P, Spirk D, Bounameaux H. Identifying acutely ill medical patients requiring thromboprophylaxis. J Thromb Haemost 2006; 04: 915-916.
- 13 Barbar S, Noventa F, Rossetto V. et al. A risk assessment model for the identification of hospitalised medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 2010; 08: 2450-2457.
- 14 Cohen AT, Alikhan R, Arcelus JI. et al. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 2005; 94: 750-759.
- 15 Barba R, Zapatero A, Losa JE. et al. Venous thromboembolism in acutely ill hospitalised medical patients. Thromb Res 2010; 126: 276-279.
- 16 Woller SC, Stevens SM, Jones JP. et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med 2011; 124: 947-954.
- 17 Nendaz M, Spirk D, Kucher N. et al. Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE). Thromb Haemost 2014; 111: 531-538.
- 18 Kucher N, Koo S, Quiroz R. et al. Electronic alerts to prevent venous thromboembolism among hospitalised patients. N Engl J Med 2005; 352: 969-977.
- 19 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.
- 20 Kucher N, Spirk D, Kalka C. et al. Clinical predictors of prophylaxis use prior to the onset of acute venous thromboembolism in hospitalised patients SWIss Venous ThromboEmbolism Registry (SWIVTER). J Thromb Haemost 2008; 06: 2082-2087.
- 21 Chopard P, Dorffler-Melly J, Hess U. et al. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med 2005; 257: 352-357.
- 22 Nendaz MR, Chopard P, Lovis C. et al. Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems. J Thromb Haemost 2010; 08: 1230-1234.
- 23 Chopard P, Spirk D, Beer HJ. et al. Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study. Swiss Med Wkly 2009; 139: 630-635.
- 24 Kucher N, Spirk D, Baumgartner I. et al. Lack of prophylaxis before the onset of acute venous thromboembolism among hospitalised cancer patients: the SWIss Venous ThromboEmbolism Registry (SWIVTER). Ann Oncol 2010; 21: 931-935.
- 25 Aujesky D, Guignard E, Pannatier A. et al. Pharmacological thromboembolic prophylaxis in a medical ward: room for improvement. J Gen Intern Med 2002; 17: 788-791.
- 26 Urbankova J, Quiroz R, Kucher N. et al. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost 2005; 94: 1181-1185.
- 27 Williamson DR, Albert M, Heels-Ansdell D. et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes. Chest 2013; 144: 1207-1215.
- 28 Decousus H, Tapson VF, Bergmann JF. et al. IMPROVE Investigators. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 2011; 139: 69-79.