Implementation of outpatient treatment of deep-vein thrombosis in private practices in Germany

Compression treatment in acute symptomatic proximal deep venous thrombosis - Results of a worldwide survey

OBJECTIVES

The aim of this study was to illustrate how compression is performed worldwide in proximal DVT and if compression management has changed recently.

METHODS

A global online survey, consisting of 36 questions, was used. The survey was solicited from membership lists of Union Internationale de Phlébologie (UIP) membership societies. For differences between the continents in comparison to Western Europe odds ratios and 95% Confidence Intervals (95%CI) where calculated.

RESULTS

We received 626 answers from 41 countries. Compression is routinely used in proximal DVT in all regions (82.8%). 81.4% start compression immediately after diagnosis. In the acute phase of DVT reduction of pain and swelling (91.7%) and PTS prevention (66.2%) are the main reasons for compression. 33.2% recently changed their compression management with 43.5% starting compression earlier and 7.0% later.

CONCLUSIONS

Compression is still used routinely in proximal DVT in addition to anticoagulation. The changes in international guidelines towards the non-routine use of compression in proximal DVT have not caused significant changes in DVT management.

Patient-reported reasons for and predictors of noncompliance with compression stockings in a randomized trial of stockings to prevent postthrombotic syndrome

INTRODUCTION

Elastic compression stockings (ECSs) are used to treat symptoms of venous insufficiency. However, lack of patient compliance can limit their effectiveness. In a secondary analysis of the SOX Trial, a randomized trial of active vs. placebo ECSs worn for 2 years to prevent postthrombotic syndrome after deep vein thrombosis, we aimed to describe patient-reported reasons for nondaily use of ECS and to identify predictors of noncompliance during follow-up.

METHODS

At each follow-up visit of the SOX Trial, patients were asked how many days per week they wore study stockings, and if not worn daily, to specify the reason(s). Reasons for nondaily use of ECSs were tabulated. Multiple logistic regression modeling was used to identify predictors of stocking noncompliance during follow-up (defined as use <3 days per week).

RESULTS

Among the 776 patients who attended at least 1 follow-up visit, daily use of stockings at each visit was similar in the active and placebo ECS groups. Reasons for nondaily use of stockings was most frequently related to aversive aspects of stockings (~three-fourths of patients) and less often related to patient behaviors (~one-fourth of patients). In multivariate analyses, behavior-related and aversive aspect-related reasons for nondaily use of ECSs at the 1-month visit were significant predictors of noncompliance during follow-up (odds ratio [OR] = 4.41 [95% confidence interval, 2.12-9.17] and OR = 3.99 [2.62-6.08], respectively).

CONCLUSIONS

Aversive aspects of ECSs and patient behaviors are important reasons for noncompliance. Improving the appeal and tolerability of ECS and education directed at modifying patient behaviors may improve compliance.

[Modern treatment of deep vein thrombosis and pulmonary embolism]

Virchow's triad has been known for a 100 years. The development of therapeutic possibilities during this time was enormous. Today anticoagulant therapy is much more differentiated. Four new oral substances have replaced the traditional treatment with vitamin K antagonists in angiology. A standardized dosage is available. The monitoring of the coagulation parameters is no longer necessary, but it is important to monitor renal function. Direct oral anticoagulants are approved for the treatment of venous thrombosis and pulmonary embolism, but not during pregnancy or in children. Severe bleeding complications, especially intracerebral bleeding, are less common. The incidence of venous thromboembolism is still high. Obesity and cancer are of particular importance. The "therapeutic pact" with the patient requires that physicians master the art of "talking medicine".

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

Review of the cost of venous thromboembolism

Background

Venous thromboembolism (VTE) is the second most common medical complication and a cause of excess length of hospital stay. Its incidence and economic burden are expected to increase as the population ages. We reviewed the recent literature to provide updated cost estimates on VTE management.

Methods

Literature search strategies were performed in PubMed, Embase, Cochrane Collaboration, Health Economic Evaluations Database, EconLit, and International Pharmaceutical Abstracts from 2003–2014. Additional studies were identified through searching bibliographies of related publications.

Results

Eighteen studies were identified and are summarized in this review; of these, 13 reported data from the USA, four from Europe, and one from Canada. Three main cost estimations were identified: cost per VTE hospitalization or per VTE readmission; cost for VTE management, usually reported annually or during a specific period; and annual all-cause costs in patients with VTE, which included the treatment of complications and comorbidities. Cost estimates per VTE hospitalization were generally similar across the US studies, with a trend toward an increase over time. Cost per pulmonary embolism hospitalization increased from $5,198–$6,928 in 2000 to $8,764 in 2010. Readmission for recurrent VTE was generally more costly than the initial index event admission. Annual health plan payments for services related to VTE also increased from $10,804–$16,644 during the 1998–2004 period to an estimated average of $15,123 for a VTE event from 2008 to 2011. Lower costs for VTE hospitalizations and annualized all-cause costs were estimated in European countries and Canada.

Conclusion

Costs for VTE treatment are considerable and increasing faster than general inflation for medical care services, with hospitalization costs being the primary cost driver. Readmissions for VTE are generally more costly than the initial VTE admission. Further studies evaluating the economic impact of new treatment options such as the non-vitamin K antagonist oral anticoagulants on VTE treatment are warranted.

Rates of elastic compression stockings prescription following the diagnosis of deep venous thrombosis among Canadian emergency physicians and trainees

Introduction Postthrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling, and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT have been shown to reduce the incidence and severity of PTS. The aim of our study was to investigate practices and perceptions of physicians regarding adjunct therapies to anticoagulation in patients diagnosed with lower extremity DVT.

METHODS

A national online survey was conducted of Canadian emergency medicine staff physicians and residents (n=471) to investigate their attitudes toward the prescription of ECS post-diagnosis of DVT. A paper survey of patients in a thrombosis clinic (n=58) was also administered to better understand the patient experiences with ECS.

RESULTS

The majority of staff physician (62%) and resident (69%) respondents were unsure of whether ECS were effective in preventing PTS and managing venous symptoms. Only 6% of staff physicians and 7% of residents routinely prescribed ECS for above-knee DVTs. More than 78% of respondents were unsure about the optimal timing of initiation of ECS and duration of therapy. Although all patients noted symptomatic relief with ECS, only 50% were prescribed stockings by an emergency or family doctor, and 69% of those patients wore the stockings on a daily basis. Staff physicians most frequently identified poor fit as the reason for lack of patient compliance, whereas patients most frequently cited cost.

CONCLUSIONS

Our findings suggest that there is variability in practice among Canadian emergency medicine physicians and trainees and a need for widespread education regarding the latest evidence of the benefit of ECS after DVT.

Compression – from thrombosis to post-thrombotic syndrome

Einleitung: Die Empfehlung von Kompression und Mobilisierung im akuten Stadium einer Thrombose, zusammen mit exakter Antikoagulation, beruht vorwiegend auf Erfahrung. Schwerpunktmäßig konzentrieren sich die meisten Therapie-Studien auf das Schicksal der Thromben. Einige randomisierte Vergleichsstudien konnten zeigen, dass ein derartiges Therapieregime nicht mit einer erhöhten Rate von Lungenembolien einhergeht.

Methode: Die Literatur wurde hinsichtlich der Fragestellung überprüft.

Ergebnisse: Subjektive Beschwerden des Patienten wurden bisher nur in einzelnen randomisiert- kontrollierten Studien untersucht, die eine Verminderung von Schmerz und Schwellung sowie eine Verbesserung der Lebensqualität zeigten. Damit wurde das Therapieprinzip Antikoagulation, Kompression und Mobilisierung zum Kern der ambulanten Thrombosetherapie.

Nach der bisher vorliegenden Evidenzlage kann eine Weiterführung der Kompression über zwei Jahre die Häufigkeit eines post-thrombotischen Syndroms signifikant reduzieren. Die Empfehlung einer Kompressionsstrumpf-Versorgung nach Thrombose, die sich auch in einschlägigen Leitlinien findet, wurde durch eine rezente kanadisch-amerikanische Multicenterstudie in Frage gestellt. In dieser Studie wurden bei Patienten mit proximaler Erstthrombose der Effekt von 30–40 mmHg-Strümpfen gegenüber jenem von „Placebo-Strümpfen“ (5 mmHg) vergli-chen. Bis zu zwei Jahren fand sich kein Unterschied zwischen beiden Gruppen, weder nach den Ginsberg-Kriterien (Schmerz und Schwellung länger als ein Monat), noch nach der Villalta-Skala (Summenscore aus subjektiven Beschwerden und klinischen Zeichen). Die Strümpfe wurden den Patienten per Post geschickt, mehr als die Hälfte der Patienten war letztlich nicht im Stande zu beurteilen, ob sie einen Therapiestrumpf oder ein Placebo bekommen hatten. Jene 55 % der Patienten, welche nach eigenen Angaben ihre Strümpfe mehr als 3 Tage pro Woche trugen, wurden als „frequent users“ eingestuft. Neben mehreren anderen Problemen mit dieser Studie bleibt die Frage offen, wie in einer „kontrollieren Studie“ ein Therapieeffekt einer Maßnahme beurteilt werden kann, die offenbar nur sporadisch angewendet wurde.

Schlussfolgerung: Der anti-inflammatorische Effekt einer guten Kompressionstherapie in Form einer Reduktion von Schmerz und Schwellung der Thromboseextremität im akuten Stadium sollte durch weitere Kompressionsbestrumpfung für einige Monate aufrecht erhalten und das weitere Procedere dann vorwiegend nach klinischen Kriterien entschieden werden. Weitere Verlaufsstudien, welche die Rolle der Kompression auf die klinische Symptomatik von der Thrombose zum postthrombotischen Syndrom untersuchen, sind zu empfehlen.

The history and historical treatments of deep vein thrombosis

Deep vein thrombosis (DVT) is a common disease. However, unlike that of varicose veins, which have been depicted since antiquity in art and literature, its description was more recent in the history of medicine. The first well-documented case of DVT was reported during the Middle Ages: in 1271, Raoul developed a unilateral edema in the ankle, which then extended to the leg. The number of reported DVT cases steadily increased thereafter, particularly in pregnant and postpartum women. During the first half of the 20th century, well before the discovery of anticoagulants, many therapeutic approaches were used, and arose from the pathologic hypotheses that prevailed at their time. Despite the development of anticoagulants, and the fact that they were thought to dramatically decrease DVT mortality, numerous complementary treatments have also been developed during the last 50 years: they include vena cava clips and surgical thrombectomy, and are intended to decrease mortality or to prevent late complications. Most of these treatments have now been abandoned, or even forgotten. In this review, we recall also the discovery and the use of vitamin K antagonists and heparin, which have constituted the mainstay of treatment for decades. We also bring some perspective to historical aspects of this disease and its treatment, notably regarding elastic compression and early mobilization, but also abandoned and complementary treatments. In these times of change regarding DVT treatment, mainly marked by the arrival of new oral anticoagulants, efforts of physicians through the ages to treat this common disease provide a beautiful example of the history of knowledge.