Chest physicians’ knowledge of appropriate thromboprophylaxis

Abstract

Venous thromboembolism (VTE) is a major cause of in-hospital mortality. Several international guidelines provide thromboprophylaxis recommendations; however, guidelines adherence is missing worldwide. We evaluated the chest physicians' knowledge regarding VTE prophylaxis, using a systematically developed questionnaire. The Prophylaxis-foR-venOus-throMbOembolism-assessmenT-questionnairE (PROMOTE) questionnaire was developed using an algorithm encompassing the most important VTE prophylaxis topics and included 13 clinical scenarios. Responses were evaluated with reference to the eighth edition of American College of Chest Physicians guidelines for VTE prevention to assess thromboprophylaxis appropriateness. The questionnaires were distributed during the fourth International Congress on Pulmonary Disease, Intensive Care and Tuberculosis. From the 88 received questionnaires (response rate: 39.8%), 82 were acceptable (62 men, 20 women). The most commonly cited VTE risk factors were immobility (79.2%), surgery (68.2%), and cancer (60.9%). The mean correct response ratio to the questions was 67% [95% confidence interval (CI) 64-70%] with highest appropriateness ratios amongst cardiologists (77.1 ± 5.8%) and lowest ratios among thoracic surgeons (59.2 ± 5%). Physicians' specialty had a significant effect on the overall appropriateness (P = 0.04) and most of appropriateness subcategories. Thoracic surgeons had the lowest rate of over-prophylaxis (P = 0.02). Years passed from graduation were inversely associated with overall appropriateness (P = 0.006). Physicians with academic engagements had a higher overall appropriateness (P = 0.04). We found a wide gap between the guideline recommendations and the responses. PROMOTE is the first systematically developed questionnaire that addresses chest physicians' thromboprophylaxis knowledge and could be useful to strategies to improve VTE prophylaxis. Because of the dissimilar prophylaxis pitfalls of different specialists, distinct educational programs seem necessary to improve their knowledge of proper VTE prophylaxis.

Prophylaxis for Venous Thromboembolism: A Great Global Divide between Expert Guidelines and Clinical Practice?

“…61 Similarly, data from 1375 (nonorthopedic) surgical patients from the DVT-FREE registry indicated that 44% of patients had received thromboprophylaxis before development of DVT. 62 However, results of studies from our group, [36][37][38] which are also harmonious with reported findings from many developing countries participating in the ENDORSE study, suggest that in developing countries, surgical patients are by far less optimally prophylaxed than medical patients. 33 Underuse of pharmacoprophylaxis and insufficient use of nonpharmacological measures in surgical patients with contraindications to pharmacoprophylaxis are among the major pitfalls in surgical patients, especially in nonorthopedic surgical procedures.…”

“…It is agreed that for many patients who receive thromboprophylaxis, dosing is not according to guideline recommendations. [34][35][36][37] In two recent studies of thromboprophylaxis we have suggested a hierarchical model for assessment of thromboprophylaxis appropriateness (►Fig. 1).…”

“…38 For many patients, a history of COPD was a strong predictor for thromboprophylaxis, even after adjustment for the ACCP risk. 37,38 Therefore, in medical inpatients, two major pitfalls seem to exist: While a large body of evidence demonstrates underprophylaxis in many atrisk medical patients, another notable problem is overprophylaxis among low-risk medical inpatients.…”

“…64 Similarly, results from the Prophylaxis-foR-venOus-throMbOembolism-assessmenT-questionnairE (PROMOTE) survey suggested that over 83% of intensivists made correct decisions regarding thromboprophylaxis prescription to at-risk patients while improvements were needed for selection of the right dosing choices for pharmacoprophylaxis. 37 Likewise, results from a multicentric study of 30 public hospital ICUs in Australia and New Zealand showed that 86% of ICU patients had received thromboprophylaxis for 44% of whom a combination of pharmacological and nonpharmacological prophylaxis was used. 65 Based on these results, it could be implied that intensivists are relatively more vigilant of thromboembolic complications and thromboprophylaxis compared with mid to late 1990s, when ICU was considered as "the last frontline for VTE prophylaxis."…”

“…Moreover, even in many of those who receive some form of prophylaxis, appropriate type, dosing, and duration are not used. [34][35][36][37] In addition, remarkable interdepartment and between-country variations exist in thromboprophylaxis patterns and pitfalls.…”