2112 Letters to the Editor
Audit-guided action can improve the compliance with thromboembolic prophylaxis prescribing to hospitalized, acutely ill older adults S . T I M M O N S , C . O ’ C A L L A G H A N , M . O ’ C O N N O R , D . O ’ M A H O N Y and C . T W O M E Y Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
To cite this article: Timmons S, O’Callaghan C, O’Connor M, O’Mahony D, Twomey C. Audit-guided action can improve the compliance with thromboembolic prophylaxis prescribing to hospitalized, acutely ill older adults. J Thromb Haemost 2005; 3: 2112–3.
We read with interest the articles by Minno and Tufano (2004) and Zakai et al. (2004), which serve to highlight the need for prevention of venous thromboembolism (VTE) in at-risk patients. We recently audited our use of prophylactic low molecular weight heparin (LMWH) in hospitalized older adults (65 years or older) over a 6-week period. Patients were included if they had an indication for thromboembolic prophylaxis as defined by our departmental guidelines (severe heart failure; acute myocardial infarction; respiratory failure; past history of thromboembolic disease; hypercoagulable state; nephrotic syndrome; acute illness with dehydration). Patients were excluded if they received therapeutic LMWH for suspected myocardial infarction or VTE, were already receiving longterm warfarin therapy, or died or were discharged within 48 h of admission. To comply with departmental guidelines, a patient had to be prescribed subcutaneous tinzaparin, 3500 units once a day, within 2 days of admission. There were three predetermined exceptions to this standard: (a) a documented contraindication to LMWH; (b) the patient had suffered a stroke, in which case they had to be either prescribed compression stockings or have a documented contraindication to these; and (c) inappropriateness of thromboembolic prophylaxis due to the patient’s overall condition (i.e. patient was moribund or terminally ill). There were 120 acute admissions to the ward during the audit period, with 16 of these cases excluded (six received therapeutic LMWH, five were taking warfarin and five died or were discharged within 48 h). Of the remaining 104 patients, 27 (26%) had an indication for thromboembolic prophylaxis. Of these, six cases (22%) met the prescribing standard, four cases were inappropriate for prophylaxis and three cases had a contraindication to LMWH. Thus, in total, only 48% of those eligible for thromboembolic prophylaxis met the prescribing standard or an exception.
Correspondence: Suzanne Timmons, Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland. Tel.: 00 353 21 4922325; fax: 00 353 21 4922829; e-mail: suzanne
[email protected] Received 10 April 2005; accepted 11 April 2005
(No case failed because of a missing drug prescription sheet, suboptimal dose of tinzaparin or the prescription of an alternative LMWH). Following discussion of the baseline audit results, a program of medical staff education on the content of the departmental guidelines, including those for VTE prevention, was initiated. In addition, a specific prompt for thromboembolic prophylaxis was inserted into the ward admission form. Data collection was subsequently repeated. On this occasion, 20 patients had an indication for thromboembolic prophylaxis. Of these, 17 received prophylaxis (85%), and one patient met a prescribing exception (receiving palliative care). Thus, there was a 90% compliance with, or exception to, the prescribing standard on this occasion, in comparison with 48% on the first occasion, a significant improvement (P < 0.02, Fisher’s exact test). It has been previously reported that hospitalized patients at risk of VTE are underprescribed thromboembolic prophylaxis [3–5]. A study of medical patients at Kings hospital, London, found that only 23% of those at high risk, and none of those at moderate risk of VTE, received prophylaxis [6]. In Italy, only 46% of patients who met the American College of Chest PhysiciansÕ consensus statement criteria received thromboembolic prophylaxis [7]. It is known that education can increase prophylaxis prescribing – Anderson described an increase from 29% to 52% [8]. Our audit cycle clearly demonstrates that thromboembolic prophylaxis prescribing can be significantly improved, at least in the short term, by a combination of education and written prompting. References 1 Di Minno G, Tufano A. Challenges in the prevention of venous thromboembolism in the elderly. J Thromb Haemost 2004; 2: 1292–8. 2 Zakai NA, Wright J, Cushman M. Risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk score. J Thromb Haemost 2004; 2: 2156–61. 3 Gillies T, Ruckley C, Nixon S. Still missing the boat with fatal pulmonary embolism. Br J Surg 1996; 83: 1394–5. 4 Stratton MA, Anderson FA, Bussey HI, Caprini J, Comerota A, Haines ST, Hawkins DW, O’Connell MB, Smith RC, Stringer KA. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Int Med 2000; 160: 334–40.
2005 International Society on Thrombosis and Haemostasis
Letters to the Editor 2113 5 Arnold D, Kahn S, Shrier I. Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines. Chest 2001; 120: 1964–71. 6 Alikhan R, Wilmott R, Agrawal S. Use of thromboprophylaxis in nonsurgical patients: survey of a London teaching hospital. Blood 2001; 98: 1142 (abstract). 7 Ageno W, Squizzato A, Ambrosini F, Dentali F, Marchesi C, Mera V, Steidl L, Venco A. Thrombosis prophylaxis in medical patients: a
retrospective review of clinical practice patterns. Haematologica 2002; 87: 746–50. 8 Anderson F, Wheeler H, Goldberg R, Hosmer D, Forcier A, Patwardhan N. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Arch Intern Med 1994; 154: 669–77.
Is there a true difference in recurrence rate of deep venous thrombosis between men and women? A . V A N H Y L C K A M A V L I E G , C . A . B A G L I N and T . P . B A G L I N Department of Haematology, Addenbrookes Hospital, Cambridge, UK
To cite this article: van Hylckama Vlieg A, Baglin CA, Baglin TP. Is there a true difference in recurrence rate of deep venous thrombosis between men and women? J Thromb Haemost 2005; 3: 2113–4. See also Baglin T, Luddington R, Brown K, Baglin C. High risk of recurrent venous thromboembolism in men. J Thromb Haemost 2004; 2: 2152–5.
The 2-year cumulative recurrence rate of deep venous thrombosis after suffering a single episode of thrombosis is approximately 10%–18% [1,2]. Recently, it was shown that the risk of recurrent venous thrombosis is higher among men than women, a difference that appeared not to be due to discontinuation of oral contraceptives or hormone replacement therapy, the presence of the factor V Leiden (FV Leiden) or the prothrombin mutation, or elevated levels of factor VIII or IX (FVIII or FIX) [3,4]. The diagnosis of recurrent deep venous thrombosis in the previously unaffected leg, i.e. the contralateral leg, is not associated with diagnostic problems that may occur due to residual thrombus mass or damage to the vessel wall caused by previous thrombosis. However, the diagnosis of recurrent deep venous thrombosis in the same leg as the first event, i.e. the ipsilateral leg, is much more difficult. Therefore, we considered that the difference in recurrence rate between men and women might be explained by a higher number of men presenting with false positive, ipsilateral recurrences, indicating that the excess recurrences in men are residual thrombi or post-thrombotic syndrome rather than new deep venous thromboses. Analyses were performed in a large prospective follow-up study, the Cambridge Venous Thromboembolism (CVTE) study. The design of this study was described in detail Correspondence: T. P. Baglin, Department of Haematology, Addenbrookes NHS Trust Hospital, Box 234, Hills Road, Cambridge, CB2 2QQ, UK. Tel.: +44 0 1223 256168; fax: +44 0 1223 217017; e-mail: trevor.
[email protected] Received 10 May 2005, accepted 16 May 2005 2005 International Society on Thrombosis and Haemostasis
previously [2]. In brief, 570 patients with a first, objectively diagnosed episode of deep venous thrombosis of the leg or a pulmonary embolism, who registered at Addenbrookes NHS Trust hospital in Cambridge between August 1997 and January 2002, were followed-up for 2 years after discontinuation of anticoagulation therapy. Patients with malignant disease at the time of registration, antiphospholipid syndrome, cerebral vein thrombosis, continued anticoagulant therapy, or proven recurrent deep venous thrombosis during anticoagulant therapy were excluded. For the current study, we only included patients with a first episode of deep venous thrombosis of the leg. Only patients with a new or extended clot, resulting in restarting anticoagulation therapy, were recorded as recurrent deep venous thrombotic events. Recurrence rates were compared between men and women using Kaplan-Meier estimates and Cox proportional hazards modeling. In total, 385 patients with a first episode of deep venous thrombosis of the leg were included in this study, 177 men and 208 women. Table 1 shows the number of recurrences that occurred during the follow-up. During follow-up, in total 30 patients had a recurrent deep venous thrombosis of the leg (7.8%). Twenty-two out of 177 men and eight out of 208 women had a recurrent event during follow-up, indicating that the total cumulative proportion of recurrent deep venous thrombosis after two years of follow-up was higher among men compared with women, i.e. 12.4% and 3.8%, respectively (HR ¼ 3.4; 95% CI: 1.5–7.6). This difference only marginally changed after exclusion of surgery and pregnancy related thrombotic events (HR ¼ 3.3; 95% CI: 1.4–7.3). Twenty-two patients (16 men and six women) were diagnosed with a recurrent deep venous thrombosis in the same leg as their first thrombotic event (ipsilateral), whereas eight patients (six
