Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients: Findings From the International Medical Prevention Registry on Venous Thromboembolism
Tapson VF, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M, Spyropoulos AC, Merli GJ, Zotz RB, Bergmann JF, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA, Fitzgerald G, Anderson FA; for the IMPROVE Investigators. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: Findings from the International Medical Prevention Registry on Venous Thromboembolism. CHEST 2007 Jun 15; [Epub ahead of print].
ABSTRACT: BACKGROUND: Evidence-based guidelines recommend that acutely ill hospitalized medical patients at risk of venous thromboembolism (VTE) should receive prophylaxis. Our aim was to characterize clinical practices for VTE prophylaxis in acutely ill hospitalized medical patients enrolled in the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE). METHODS: IMPROVE is an ongoing, multinational, observational study. Participating hospitals enroll the first 10 consecutive eligible acutely ill medical patients each month. Patient management is determined by the treating physicians. An analysis of data on VTE prophylaxis practices is presented. RESULTS: From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the USA and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis, or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis, actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the USA, although it was used very rarely in other countries (22% vs 0.2%). Unfractionated heparin was the most frequent pharmacologic approach used in the USA (21% of patients), with low molecular weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the USA and other participating countries (3% vs 7%, respectively). CONCLUSIONS: Our data suggest that physicians' practices for providing VTE prophylaxis to acutely ill hospitalized medical patients are suboptimal, and highlight the need for improved implementation of existing evidence-based guidelines in hospitals.
Current VTE Prophylaxis Patterns are Suboptimal in Acutely Ill Medical Patients
Review by Gregory Piazza, MD
How well do clinicians follow evidence-based guidelines for the venous thromboembolism (VTE) prophylaxis of acutely ill hospitalized medical patients? This analysis from the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) evaluated VTE prophylaxis patterns among 15,156 hospitalized medical patients from 52 medical centers and 12 countries. In the United States and other participating countries, 52% and 43% of hospitalized medical patients, respectively, should have received VTE prophylaxis according to the American College of Chest Physicians (ACCP) guidelines. Of these patients who met the ACCP criteria for VTE prophylaxis or those who were eligible based on enrollment criteria for randomized clinical trials demonstrating a benefit from pharmacological prophylaxis, less than two-thirds actually received prophylaxis. Although rarely used in other countries, intermittent pneumatic compression was the most common form of prophylaxis among patients enrolled in the United States. While low-molecular weight heparins were most frequently used in other countries, subcutaneous unfractionated heparin was the most common pharmacological modality in the United States.
Although the study was not a randomized controlled trial, the large IMPROVE registry analysis provides an important “real-world” view of VTE prophylaxis patterns among acutely ill medical patients in the United States and abroad. Similar to other recent studies, IMPROVE highlights critical deficiencies in the implementation of VTE prophylaxis according to established guidelines among the vulnerable patient population of hospitalized medical patients.
The IMPROVE registry should be viewed as an important call-to-action for clinicians and investigators to seek new ways of improving implementation of evidence-based guidelines for VTE prophylaxis among acutely ill hospitalized medical patients.
About Gregory Piazza, MD: Dr. Piazza completed medical Internship and Residency at the Beth Israel Deaconess Medical Center in Boston, Massachusetts. He also served as a Chief Medical Resident at the Beth Israel Deaconess Medical Center. Dr. Piazza is currently a third year clinical fellow in the Cardiovascular Division at the Beth Israel Deaconess Medical Center. His Clinical research is undertaken simultaneously at the Venous Thromboembolism Research Group, where he is focusing on characteristics of hospitalized medical patients with DVT and complications of anticoagulation management.