Trends of Ordering Hypercoagulability Work-Up at an Academic Medical Center

Abstract

Background Venous thromboembolism is a significant clinical event, with an annual incidence of 1–2 per 1000 population. Risk factors include recent surgery, prolonged immobility, oral contraceptive use, and active cancer. Inherited risks include protein C and S deficiencies, antithrombin deficiency, factor V Leiden mutation and prothrombin. These factors can be tested to guide therapy, but current evidence suggests that testing for inherited thrombophilia is not recommended in most inpatient settings. In the era of high value care, hypercoagulable testing for VTE creates a financial burden for the hospital and patients. We performed a retrospective chart review of hypercoagulable orders on VTE patients at our institution. Methods Institutional Review Board approval was obtained. A total of 287 adult patients admitted over a 3-month period with the diagnosis of VTE were included. Patients were identified via ICD-10 codes and data were collected from electronic medical records. Patient characteristics, provoked versus unprovoked VTE, and relative contraindications for hypercoagulability work-up were analyzed. Our primary outcome was to assess the appropriateness of thrombophilia testing in VTE patients based on screening guidelines. Our secondary outcome was to analyze the cost burden of ordering these tests. Results A total of 287 patients were included in our data analysis. Patient risk factors for VTE were malignancy, previous DVT, immobilization, surgery 3 months prior, and central line placement. Fifty-seven of 287 patients had at least one hypercoagulable test ordered during hospitalization which did not adhere to guidelines. Misuse of testing occurred during active thrombosis, active anticoagulation, presence of risk factors, first episode of VTE, and malignancy. The cost of ordering these 5 thrombophilia tests totaled over $40,000. Conclusion In our study, numerous patients were tested without compliance to standard recommendations, which created financial and value-based burdens on our health care system. Increased awareness among clinicians is thus warranted to ensure high value care.

Adherence to Thrombophilia Testing Guidelines and its Influence on Anticoagulation Therapy: A Single-Center Cross-Sectional Study

“…Despite these differences and inclusion of patients with any reason for referral for thrombophilia testing, the prevalence of thrombophilia in our study (34 %) aligned well with that in other European and US studies, in which hereditary thrombophilia was confirmed in about a third of the patients with VTE [43,44]. Adherence to thrombophilia guidelines has been investigated in acute in hospital care and other departments than hematology [17,19,20,[44][45][46] and was found to be poor. To our knowledge, this is the first study reporting data from a tertiary hematology center comprising all types of indications for consultation.…”

“…Testing was not performed or missing for factor V Leiden mutation (6 %), prothrombin G20210A mutation (13 %), antithrombin (20 %), protein C (30 %), protein S (29 %), antiphospholipid syndrome (11 %). more frequently included patients with pre-existing co-morbidities or major risk factors than our study [5,17,41]. Differences between patient characteristics can likely be explained by different settings, because patients in our study were selected and referred by general practitioners or other specialists.…”

“…The adherence to thrombophilia testing guidelines is low in acute hospital care and disciplines other than hematology [4,[17][18][19]. Better adherence was shown for hematologists in a small retrospective study [20].…”

“…Better adherence was shown for hematologists in a small retrospective study [20]. Previous studies mainly focus on adherence for thrombophilia testing in patients with VTE [4,17], whereas studies of patients with arterial thrombosis or pregnancy-related morbidity, and asymptomatic persons with a family history of VTE are lacking.…”

Inpatient thrombophilia workup; does hematology consult prevent unnecessary testing?

“…These findings are consistent with previous published retrospective studies that demonstrated inappropriate testing. 1,7,8 The American Heart Association (AHA) has published guidelines that outline risk factors to help determine whether an event is provoked by a transient risk factor, due to permanent risk factors or unprovoked. Risk factors include major surgery, trauma, spinal cord injury, bed rest, malignancy, oral contraceptives, hormone replacement therapy, pregnancy, age, obesity, congestive heart failure, previous thromboembolism and thrombophilia.…”