Venous thromboembolism prophylaxis: quality, location (hospital vs. home), and duration.

Thromb Haemost 2009; 102: 1–2 Venous thromboembolism (VTE) prophylaxis for hospitalised patients at risk for deep venous thrombosis (DVT) or pulmonary embolism (PE) has been underutilised. Consequently, VTE has been identified as the number one cause of preventable death among hospitalised patients. Deaths and non-fatal VTE caused by failure to prophylax occur not only in the hospital but continue for at least several months after hospital discharge. Government policy makers, patients, and health care providers have declared that the contrast between our in-depth knowledge of how to prevent VTE and our lackadaisical implementation of prophylactic measures is unacceptable. In 2008, Steven K. Galson, MD, MPH issued The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism (1). The Surgeon General estimates that in the United States alone, 100,000 to 180,000 deaths occur annually because of VTE. He states that although “we have made progress in our knowledge of how to prevent, diagnose and treat DVT/PE..., it is also clear that we are not applying that knowledge on a systematic basis.” Meanwhile, Medicare has devised a financial incentive for hospitals to enforce VTE prophylaxis among high-risk patients. Medicare is now authorised to withhold payment to hospitals for treatment of serious preventable complications termed „never events.“ Examples of “never events” include leaving a surgical instrument in the abdomen or transfusing blood with incompatible blood types. Medicare will not pay the incremental cost to manage a “never event,” such as repeat surgery to remove the forgotten surgical instrument or additional hospital care to treat a transfusion reaction resulting from major blood type incompatibility. Rather, the hospital where the error occurred will bear the additional financial burden (2). As of October 1, 2008, Medicare declared the occurrence of VTE after total knee or hip replacement to be a “never event.” This means that hospitals will have to pay for the extra costs of treating postoperative DVT or PE following knee or hip replacement. Quality improvement programs have tried to increase in-hospital VTE prophylaxis rates, because this metric is readily obtainable and easy to understand. Focus is placed on the percent of high-risk hospitalised patients who are receiving VTE prophylaxis. However, this simple statistic does not tell the whole story. The methodology for assessing quality of VTE prophylaxis is far more complex. Patients receiving pharmacological prophylaxis require the right drug, the correct dose, and the optimal dosing regimen with respect to duration of anticoagulant. Those patients with active bleeding or at very high risk of bleeding should receive prophylaxis, but with mechanical measures such as graduated compression stockings or intermittent pneumatic compression devices rather than with anticoagulants. The duration of VTE prophylaxis should extend beyond hospitalisation if the risk factors for PE or DVT have not diminished by the time of hospital discharge. Evidence is compelling that VTE can strike after hospitalization (3). In a survey of 1,897 patients with VTE in the Worcester, Massachusetts area, 74% developed DVT or PE in the outpatient setting; 23% had undergone surgery and 37% had been hospitalised within the prior three months. Of the 516 who had been hospitalised and subsequently developed VTE, 67% developed VTE within one month of the preceding hospitalisation encounter. In a separate prospective RIETE registry of patients with acute VTE, 1,602 postoperative patients were identified (4). The average time elapsed from surgery to acute VTE was three weeks. These findings indicate the need to consider extended VTE prophylaxis after hospital discharge. A collaboration among 14 Swiss hospitals has addressed the issue of quality of VTE prophylaxis. The effort was led by Christoph Kalka of Berne and is reported in the current issue of Thrombosis and Haemostasis (5). They focused on high-risk major orthopaedic or cancer surgery patients and achieved a remarkable rate of 96% in-hospital prophylaxis. I am not aware of any other study that can match these outstanding results for prophylaxis of high-risk hospitalised patients. Under current quality assessment guidelines, this accomplishment will receive universal praise. However, these investigators took the extra, important step of asking whether VTE prophylaxis was appropriately extended after hospital discharge. Orthopaedic surgery patients did © 2009 Schattauer GmbH, Stuttgart