Primary prevention of venous thromboembolism in elderly medical patients

Formal and informal venous thromboembolism risk assessment and impact on prescribing of thromboprophylaxis: a retrospective cohort study

BACKGROUND

Hospital-acquired thrombosis (HAT) is a leading cause of preventable death and disability worldwide. HAT includes any venous thromboembolic (VTE) event occurring in-hospital or within 90-days of hospitalisation. Despite availability of evidence-based guidelines for HAT risk assessment and prophylaxis, guidelines are still underutilised.

AIM

To determine the proportion of patients who developed HAT that could have been potentially prevented with appropriate VTE risk assessment and prophylaxis at a large public hospital in New Zealand. Additionally, the predictors of VTE risk assessment and thromboprophylaxis were examined.

METHOD

VTE patients admitted under general medicine, reablement, general surgery, or orthopaedic surgery service were identified using ICD-10-AM codes. Data were collected on patient characteristics, VTE risk factors, and the thromboprophylaxis regimen prescribed. The hospital VTE guidelines were used to determine rates of VTE risk assessment and the appropriateness of thromboprophylaxis.

RESULTS

Of 1302 VTE patients, 213 HATs were identified. Of these, 116 (54%) received VTE risk assessment, and 98 (46%) received thromboprophylaxis. Patients who received VTE risk assessment were 15 times more likely to receive thromboprophylaxis (odds ratio [OR] = 15.4; 95% CI 7.65-30.98) and 2.8 times more likely to receive appropriate thromboprophylaxis (OR = 2.79; 95% CI 1.59-4.89).

CONCLUSION

A large proportion of high-risk patients who were admitted to medical, general surgery and reablement services and who developed HAT did not receive VTE risk assessment and thromboprophylaxis during their index admission, demonstrating a significant gap between guideline recommendations and clinical practice. Implementing mandatory VTE risk assessment and adherence to guidelines to improve thromboprophylaxis prescription in hospitalised patients may help reduce the burden of HAT.

VTE Prophylaxis Therapy: Clinical Practice vs Clinical Guidelines

INTRODUCTION

Venous thromboembolism (VTE) is the most preventable complication in hospitalized patients. The main objective of this study was to evaluate the adherence of current clinical practice to the established guidelines at a Palestinian teaching hospital.

METHODS

This cross-sectional, retrospective, observational study was conducted at a Palestinian Teaching Hospital. The medical records of patients admitted to the medical floor over 18 years of age and hospitalized for longer than 24 hours between January 1 and May 31, 2019, were included. Patients taking anticoagulants with incomplete or duplicated medical records were excluded from the study. A data collection sheet was developed, and clotting and bleeding risks were assessed using the Padua and IMPROVE risk assessment models (scores). The data were analyzed using IBM SPSS (version 25).

RESULTS

In total, 408 patients were included in the study, 222 of whom received thromboprophylaxis (54.4%). Of the hospitalized patients, 112 (27.5%) had a high risk of developing VTE (Padua score ≥ 4), and 73 patients were eligible for VTE pharmacological prophylaxis; however, only 44 (60.3%) received the appropriate prophylaxis. In addition, 296 patients had low Padua scores, indicating that pharmacological prophylaxis was not indicated. However, 144 (48.6%) patients received prophylaxis. The mean Padua and IMPROVE risk scores were 2.25 ± 2.08 and 4.44 ± 2.72, respectively. Among the patients, 17.6% had a high risk of bleeding (IMPROVE score ≥ 7).

CONCLUSION

VTE prophylaxis among hospitalized medically ill patients was mostly inappropriate; 80.18% of the patients received inappropriate prophylaxis, and only 60.3% of eligible patients received appropriate prophylaxis. Adapting assessment models or checklists in clinical practice based on clinical guidelines for VTE risk stratification is a practical and effective method to improve VTE prophylaxis management and select the appropriate therapy to prevent toxicity or complication.

Safety and effectiveness of thromboprophylaxis use in hospitalized elderly medical patients at a Saudi tertiary care center

Introduction

Appropriate prescribing of thromboprophylaxis according to guidelines' recommendations can heighten over- or underutilization risk. The study intended to evaluate the safety and effectiveness of appropriate/inappropriate thromboprophylaxis use among hospitalized elderly medical patients.

Methods

A retrospective observational cohort study was conducted, including patients who were ≥60 years old, hospitalized for an acute medical illness that required hospitalization in a medical ward for >48 h, and received thromboprophylaxis. Against the American College of Chest Physicians guidelines, the thromboprophylaxis use appropriateness was assessed.

Results

A total of 370 patients met the inclusion criteria, in 71.9% of whom thromboprophylaxis use was appropriate. The mean age of the included patients was 75 years (±9.1), and 72.4% of them were at high risk of venous thromboembolism (VTE), and almost all these patients received appropriate thromboprophylaxis. The occurrence of bleeding was significantly higher in the appropriate use group during hospitalization than the inappropriate use group (11.7% vs. 2.9%, p = 0.009); the majority of these bleeding events were classified as major. There were no differences in VTE events during hospitalization or 90 days all-cause mortality between the two groups.

Conclusion

The study demonstrates high prescribers' compliance with recommendations in high-risk patients. In patients at low risk for VTE, the overutilization of thromboprophylaxis did not increase their bleeding risk. This study suggests that the benefits of thromboprophylaxis in elderly patients, regardless of their VTE risk, may outweigh the risk of bleeding.

Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in at-risk patient groups: pregnancy, elderly and obese patients

BACKGROUND

Venous thromboembolism (VTE) accounts for an estimated 900,000 cases per year in the US alone and constitutes a considerable burden on healthcare systems across the globe.

OBJECTIVE

To understand why the burden is so high, qualitative and quantitative research was carried out to gain insights from experts, guidelines and published studies on the unmet clinical needs and therapeutic strategies in VTE prevention and treatment in three populations identified as being at increased risk of VTE and in whom VTE prevention and treatment were regarded as suboptimal: pregnant women, the elderly and obese patients.

METHODOLOGY

A gap analysis methodology was created to highlight unmet needs in VTE management and to discover the patient populations considered most at risk. A questionnaire was devised to guide qualitative interviews with 44 thrombosis and haemostasis experts, and a review of the literature on VTE in the specific patient groups from 2015 to 2017 was completed. This was followed by a Think Tank meeting where the results from the research were discussed.

RESULTS

This review highlights the insights gained and examines in detail the unmet needs with regard to VTE risk-assessment tools, biomarkers, patient stratification methods, and anticoagulant and dosing regimens in pregnant women, the elderly and obese patients.

CONCLUSIONS

Specifically, in pregnant women at high risk of VTE, low-molecular-weight heparin (LMWH) is the therapy of choice, but it remains unclear how to use anticoagulants when VTE risk is intermediate. In elderly patients, evaluation of the benefit of VTE prophylaxis against the bleeding risk is particularly important, and a head-to-head comparison of efficacy and safety of LMWH versus direct oral anticoagulants is needed. Finally, in obese patients, lack of guidance on anticoagulant dose adjustment to body weight has emerged as a major obstacle in effective prophylaxis and treatment of VTE.

Effectiveness and safety of oral direct factor Xa inhibitors for the treatment of venous thromboembolism in patients with cancer and/or older age

Venous thromboembolism (VTE) is a multifactorial disease. Cancer and older age are risk factors for both recurrent VTE and bleeding under anticoagulant therapy. Oral direct factor Xa inhibitors (Xa inhibitors) have been widely used to treat VTE. However, their effectiveness and safety in cancer and elderly patients have not been fully elucidated. A total of 187 consecutive patients who started Xa inhibitors for VTE therapy between September 2014 and September 2016 were recruited. Patients' demographics, changes in VTE amount, VTE recurrence, clinically relevant bleeding, and death until February 2017 were compared between 92 cancer and 95 non-cancer patients, and 57 elderly (≥ 75 years) and 130 non-elderly patients. Compared with non-cancer patients, cancer patients had a significantly higher incidence of deep vein thrombosis (DVT) in the proximal legs, superior vena cava, and upper extremities (p = 0.034), although the patients' demographics and incidence of pulmonary thromboembolism (PE) were similar between the two groups. There were no significant differences in VTE recurrence (p = 0.328) and clinically relevant bleeding (p = 0.078) between the two groups. Death occurred in 29 cancer patients, 23 of whom died of cancer, while there were no deaths among the non-cancer patients. Elderly patients had a lower body weight and creatinine clearance than non-elderly patients. No significant differences between the two groups were found in relation to PE (p = 0.544), DVT site (p = 0.054), recurrent VTE (p = 0.194), clinically relevant bleeding (p = 0.130) and death (p = 0.241). In comparisons among the four groups (elderly and non-elderly patients with and without cancer), recurrent VTE and clinically relevant bleeding were comparable (p = 0.493 and 0.227, respectively), while death was more frequent in cancer patients regardless of age (p < 0.001). The efficacy and safety of Xa inhibitors as VTE treatment were comparable between cancer and non-cancer patients, and in elderly and non-elderly patients. This suggests that Xa inhibitors may be promising drugs for VTE treatment, irrespective of age and comorbid cancer.

Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial

OBJECTIVES

To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention.

DESIGN

A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use.

SETTINGS

Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively.

PARTICIPANTS

Patients hospitalized between January 1 and May 31, 2015, in participating departments.

MEASUREMENTS

The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome.

RESULTS

We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group.

CONCLUSIONS/IMPLICATIONS

This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards.

Use of direct oral anticoagulants with regional anesthesia in orthopedic patients

The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.

Pharmacodynamics assessment of Bemiparin after multiple prophylactic and single therapeutic doses in adult and elderly healthy volunteers and in subjects with varying degrees of renal impairment

INTRODUCTION

Aging and renal impairment may prolong the half-life and lead to accumulation of low molecular weight heparins. Correct dosing is critical to prevent bleeding or thrombosis.

MATERIALS AND METHODS

Open, parallel study. Healthy adult [n=13] and elderly (>65yrs) [n=12] volunteers; and subjects with mild (ClCr≥50 to ≤80mL/min, n=8), moderate (ClCr≥30 to <50mL/min, n=7), and severe (ClCr<30mL/min, n=8) renal impairment received four prophylactic doses (3,500IU/24h) and a single therapeutic dose (115IU/kg) of bemiparin with an interim washout period. Anti-FXa activity and the potential need for dose adjustment were evaluated.

RESULTS

There were statistically significant differences in the severe renal impairment group vs. adult volunteers in all anti-FXa related parameters, but no significant differences in any of the anti-FXa related parameters between the adult and the elderly. Anti-FXa simulations after 10 prophylactic doses predicted mean Amax=0.59IU/mL in subjects with severe renal impairment and 0.33-0.39IU/mL in the rest. Simulations in the severe renal impairment group with dose adjustment (2,500IU/24h) predicted all individual Amax<0.60IU/mL (mean Amax=0.42IU/ml). Simulations after 10 therapeutic doses predicted mean Amax=1.22IU/mL in severe renal impairment group and 0.89-0.98IU/mL in the rest. Simulations in the severe renal impairment group with 75% dose adjustment predicted individual Amax≤1.60IU/mL (mean Amax=0.91IU/mL).

CONCLUSIONS

No dose adjustments are required in elderly with preserved renal function. A dose adjustment of bemiparin is only advisable in patients with severe renal impairment when using prophylactic or therapeutic doses.

Venous thromboembolism in nursing home residents: role of selected risk factors

OBJECTIVES

To provide nursing home (NH)-specific estimates to assess whether venous thromboembolism (VTE) risk factors identified for the general population apply to NH residents.

DESIGN

Population-based case-control study.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

All county residents with symptomatic objectively diagnosed incident VTE while resident in a NH from 1988 through 2000 (N = 182) and two age-, sex-, calendar-year-matched non-VTE Olmsted County NH residents per case (N = 364).

MEASUREMENTS

Provider-linked medical records were reviewed to obtain information on active malignancy and recent hospitalization, surgery, trauma, or fracture as of index date (case's VTE date; respective provider registration date for controls). Risk factor prevalence and VTE-associated odds ratios (OR) were estimated and compared with previously obtained data for all Olmsted County residents from 1988 through 2000. For analyses, both groups were limited to individuals aged 65 and older.

RESULTS

In NH residents, active malignancy, recent hospitalization, and recent surgery significantly increased VTE risk, but the magnitude of risk appeared much lower than general population estimates (e.g., for major surgery, OR = 2.5, 95% confidence interval (CI) = 1.4-4.3 for NH residents vs OR = 11, 95% CI = 7.0-17 for general population). In general, the prevalence of all evaluated VTE risk factors appeared much higher in NH controls than in general population controls. Thromboprophylaxis rates appeared higher for NH cases and controls than in the general population; disconcertingly, 47% of NH cases received prophylaxis.

CONCLUSION

Although general population VTE risk factors (active cancer and recent hospitalization or surgery) can identify NH residents at higher risk for VTE, these exposures do not adequately stratify VTE risk for thromboprophylaxis recommendations. Further research into NH-specific risk factors and prophylaxis effectiveness is required.