Excess venous thromboembolism prophylaxis common among low-, high-risk patients
Approximately 65% of patients with either low or high risk for venous thromboembolism events received excessive prophylaxis, according to findings published in JAMA Internal Medicine.
“National guidelines recommend objective risk stratification for venous thromboembolism in hospitalized medical patients,” Paul J. Grant, MD, from the University of Michigan School of Medicine, and colleagues wrote.
Grant and colleagues analyzed data from the Michigan Hospital Medicine Safety Consortium to investigate whether patients admitted to a non-ICU for 2 or more days (n = 44,775; mean age, 64.7 years; 55.3% women; mean hospital stay, 4.4 days) were receiving appropriate venous thromboembolism prophylaxis.
The researchers used the Padua Prediction Score risk assessment model to categorize patients as high or low risk for venous thromboembolism events. A total of 32,549 participants were identified as low risk for venous thromboembolism, while 1,804 were identified as high risk with a contraindication to pharmacologic prophylaxis and 10,422 were identified as high risk without a contraindication for pharmacologic prophylaxis.
Low-risk patients receiving pharmacologic or mechanical prophylaxis, high-risk patients with a contraindication receiving pharmacologic prophylaxis and any patient receiving both pharmacologic and mechanical prophylaxis were categorized as receiving excessive venous thromboembolism prophylaxis.
High-risk patients without a contraindication who did not receive pharmacologic prophylaxis and high-risk patients with a contraindication who did not receive pharmacologic or mechanical prophylaxis were categorized as not receiving enough venous thromboembolism prophylaxis.
Patients who received either 5,000 U of heparin twice daily, 5,000 U of heparin three times daily, 7,500 U of heparin three times daily, 40 mg of enoxaparin per day, 30 mg of enoxaparin per day, 30 mg of enoxaparin twice daily, 5,000 U of dalteparin daily or 2.5 mg of fondaparinux per day were categorized as having received appropriate pharmacologic prophylaxis.
The researchers found that 77.9% of low-risk patients, 32.3% of high-risk without a contraindication and 26.9% of high-risk patients with a contraindication received excess prophylaxis. Compared with high-risk patients, those with low risk had a three times greater likelihood of receiving excess prophylaxis (95% CI, 2.36-4.51).
Hospitals showed varying rates of excess venous thromboembolism prophylaxis. These rates ranged from 8.2% to 84.6% (mean, 32.8%) in high-risk patients and from 15.5% to 99.6% in low-risk patients (mean, 79.7%).
Venous thromboembolism prophylaxis was underused in 22% of high-risk patients. High-risk patients without a contraindication had higher rates of underuse than those with a contraindication (23.7% vs. 12.5%).
Hospitals showed varying rates of venous thromboembolism prophylaxis underuse. These rates ranged from 4.6% to 62.1% (mean, 21.3%) in high-risk patients, similar to that of low-risk patients.
Higher rates of excessive venous thromboembolism prophylaxis were associated with lower rates of prophylaxis underuse among hospitals (Pearson correlation coefficient, –0.48; 95% CI, –0.66 to –0.23).
“After years of promoting aggressive [venous thromboembolism] prophylaxis strategies for hospitalized patients, renewed effort to scale back — or ‘deimplement’ —this practice in low-risk patients may be necessary,” Grant and colleagues concluded. “Discontinuing conventional practices, however, can be difficult, even in the presence of newer compelling data.” – by Alaina Tedesco
Disclosure: The authors report no relevant financial disclosures.