Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients

Wein, Lironne; Wein, Sara; Haas, Steven Joseph; Shaw, James; Krum, Henry

doi:10.1001/archinte.167.14.1476

Cited by 166 publications

(147 citation statements)

References 66 publications

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“…Venous thromboembolism (VTE) is a major source of morbidity and mortality for hospitalized patients, with as many as 16% of high-risk medical patients developing VTE during their hospital stay. 1,2 Pharmacologic prophylaxis with subcutaneous heparin reduces the risk of VTE by approximately 50%, 3,4 and guidelines produced by the American College of Chest Physicians (ACCP) recommend thromboprophylaxis for patients at moderate-to-high risk of VTE with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). 2 UFH is less expensive per dose, but meta-analyses have suggested that UFH may be either less effective than LMWH 3 or more likely to cause complications, such as bleeding 5 or heparin-induced thrombocytopenia (HIT).…”

Section: Resultsmentioning

confidence: 99%

Comparative effectiveness of low‐molecular‐weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

Rothberg

Pekow

Lahti³

et al. 2012

Journal of Hospital Medicine

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BACKGROUND:Both unfractionated heparin (UFH) and low‐molecular‐weight heparin (LMWH) are approved for venous thromboembolism (VTE) prophylaxis. Which agent is superior remains controversial.OBJECTIVE:To compare the effectiveness, complications, and costs of UFH and LMWH as VTE prophylaxis for hospitalized medical patients.DESIGN:Retrospective cohort.SETTING:Three hundred thirty‐three acute care facilities in 2004–2005.PATIENTS:Adults with 4 common medical diagnoses considered to carry moderate‐to‐high risk of VTE. Excluded were patients on warfarin or with hospital stays of ≤2 days. VTE prophylaxis was assessed from billing data.INTERVENTION:None.MEASUREMENTS:VTE, major bleeding or heparin‐induced thrombocytopenia, mortality, and cost.RESULTS:Of 32,104 patients who received prophylaxis, 55% received LMWH and the remainder received UFH. The hospital where the patient obtained care was the strongest predictor of receiving LMWH. VTE was observed in 163 (0.51%) patients; complications, followed by stopping therapy, were rare (<0.2%). In analysis adjusted for the propensity for UFH and other covariates, patients treated with UFH had an odds ratio for VTE of 1.04 (95% confidence interval [CI] 0.76 to 1.43) compared to LMWH. In a grouped treatment model, the odds of VTE with UFH was 1.14 (95% CI 0.72 to 1.81). Adjusted odds of bleeding with UFH compared to LMWH were 1.64 (95% CI 0.50 to 5.33), adjusted odds of complications followed by stopping prophylaxis were 2.84 (95% CI 1.43 to 45.66), and adjusted cost ratio was 0.97 (95% CI 0.90 to 1.05).CONCLUSIONS:For VTE prophylaxis, the effectiveness and cost of LMWH and UFH are similar, but LMWH is associated with fewer complications. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

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Section: Resultsmentioning

confidence: 99%

Comparative effectiveness of low‐molecular‐weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

Rothberg

Pekow

Lahti³

et al. 2012

Journal of Hospital Medicine

View full text Add to dashboard Cite

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“…4,15 At the same time, prophylaxis costs money, is uncomfortable, and carries a small risk of bleeding and heparin-induced thrombocytopenia. Given the generally low incidence of symptomatic VTE, it therefore makes sense to reserve prophylaxis for patients at higher risk of thromboembolism.…”

Section: Discussionmentioning

confidence: 99%

“…4 19). We considered the following to be treatments for VTE: intravenous unfractionated heparin, >60 mg of enoxaparin, !7500 mg of dalteparin, or placement of an inferior vena cava filter.…”

Section: Identification Of Vtementioning

confidence: 99%

“…Among medical patients at the highest risk, as many as 15% can be expected to develop a VTE during their hospital stay 1,2 ; however, among general medical patients, the incidence of symptomatic VTE is less than 1%, 1 and potentially as low as 0.3%. 3 Thromboprophylaxis with subcutaneous heparin reduces the risk of VTE by approximately 50%, 4 and is therefore recommended for medical patients at high risk. However, heparin also increases the risk of bleeding and thrombocytopenia and thus should be avoided for patients at low risk of VTE.…”

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confidence: 99%

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Risk factor model to predict venous thromboembolism in hospitalized medical patients

Rothberg

Lindenauer

Lahti³

et al. 2011

Journal of Hospital Medicine

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BACKGROUND:The Joint Commission requires that all medical inpatients be assessed for venous thromboembolism (VTE) risk, but available risk stratification tools have never been validated.METHODS:We conducted a retrospective cohort study of patients age ≥18 years, admitted to 374 US hospitals in 2004–2005, with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection, and length of stay ≥3 days. Subjects were randomly assigned (80/20) to a derivation or validation set. We then assessed VTE (International Classification of Diseases, Ninth Revision [ICD‐9] code plus diagnostic test plus treatment), patient demographics, 21 potential risk factors, and other comorbidities. We created a VTE risk stratification tool using multivariable regression modeling and applied it to the validation sample.RESULTS:Of 242,738 patients, 612 (0.25%) patients fulfilled our criteria for VTE during hospitalization, and an additional 440 (0.18%) were readmitted for VTE within 30 days (overall incidence of 0.43%). In the multivariable model, age, sex, and 10 additional risk factors were associated with VTE. The strongest risk factors were inherited thrombophilia (OR 4.00), length of stay ≥6 days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. In the validation set, the model had a c‐statistic of 0.75 (95% CI 0.71, 0.78). Deciles of predicted risk ranged from 0.11% to 1.46% with observed risk over the same deciles from 0.17% to 1.81%.CONCLUSIONS:The risk of symptomatic VTE in general medical patients is low. A risk factor model can identify those at sufficient risk to warrant pharmacologic prophylaxis. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

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“…Optimization of several of these processes of care can reduce hospital morbidity, mortality, and length of stay. [18][19][20][21] As health care financing reform arrives in the US, the ability of American hospitals to manage admission-specific processes of care with reliability will become more vital. 3 In the US, programs that force hospitalists to make ad hoc, moment-to-moment prioritizations about when and where to perform admissions, discharges, and daily ward care may do so at the expense of system predictability, standardization, and patient-centeredness.…”

Section: Weaknesses and Strengths Of Acute Medicine Model Applicable mentioning

confidence: 99%

Acute medicine in the United Kingdom: First‐hand perspectives on a parallel evolution of inpatient medical care

Smith

Stein

Jones

2012

Journal of Hospital Medicine

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Pharmacological Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients

Abstract: Background: There is uncertainty regarding which pharmacological agents most effectively prevent venous thromboembolism in hospitalized medical patients. We therefore performed a meta-analysis to determine this.

Cited by 166 publications

References 66 publications

Comparative effectiveness of low‐molecular‐weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

Comparative effectiveness of low‐molecular‐weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients

Risk factor model to predict venous thromboembolism in hospitalized medical patients

Acute medicine in the United Kingdom: First‐hand perspectives on a parallel evolution of inpatient medical care

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