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Epidemiology of VTE in the US: The Opportunity for Prevention Looms Large

Epidemiology of VTE in the US: The Opportunity for Prevention Looms Large. Robert Pendleton, MD- Associate Professor Clinical Medicine Director, University Healthcare Thrombosis Service Co-Director, General Medicine Hospitalist Program

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Epidemiology of VTE in the US: The Opportunity for Prevention Looms Large

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  1. Epidemiology of VTE in the US: The Opportunity for Prevention Looms Large Robert Pendleton, MD- Associate Professor Clinical Medicine Director, University Healthcare Thrombosis Service Co-Director, General Medicine Hospitalist Program General Internal Medicine, University of Utah October 21, 2009

  2. Objectives • Appreciate the epidemiology of VTE and the impact of a dynamic and changing health care environment • Recognize the current gaps in the prevention of health care associated VTE • Realize successful strategies to improve VTE prevention on a systematic level and the potential impact on reducing VTE event rates

  3. Case of Mrs. S 68yo obese female with stage III ovarian cancer was admitted to the hospital with RLL pneumonia and sepsis. Mobility limited due to dyspnea and general fatigue. She received antibiotics & improved. In the hospital for 4 days and then discharged home. 5 Days after discharge was found dead in her home. Autopsy revealed…

  4. VTE Prevention: A National Quality Priority2008 Surgeon General’s Report: Call to Action… Rear Admiral Steven K. Galson. MD. MPH http://www.natfonline.org/call-to-action-on-dvt-2008.pdf

  5. Venous Thromboembolism Is Common(Annual U.S. Event Rates) • Blood 2005; 106:Abstract 910 ArchIntMed 2008; 168:425

  6. VTE is A Common Cause of Death In The United States http://www.cdc.gov/nchs/fastats/lcod.htm (accessed Sept 25,2009) & Blood 2005; 106:Abstract 910

  7. VTE Incidence is Increasing J G IM 2006; 21:722

  8. VTE Risk Increases with Age(Age-Related VTE Attack Rates per 100,000 population) Spencer et al. J General Internal Medicine (2006); : 722-727

  9. Overall- Attributable Risks Are Common In Patients With VTE Spencer F et al. Arch Intern Med. 2007;167:1471-1475 Heit et al Arch Intern Med 2002; 162:1245

  10. Strong Association Between Cancer & Venous Thromboembolism • Oncology patients account for over 20% of VTE events. • VTE is an independent predictor of decreased survival in cancer patients (HR 1.6-4.2). • VTE is second leading cause of death in patients with overt malignant neoplasm. Chew et al. Arch Intern Med. 2006;166:458-464 Heit . Arterioscler Thromb Vasc Biol. 2008;28:370-372)

  11. 7.0 Retrospective cohort study, University HealthSystem Consortium database of 1,824,316 hospitalizations at 133 US medical centers 6.5 6.0 5.5 5.0 4.5 4.0 Rate of VTE (%) 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 VTE- patients on chemotherapy DVT-all patients VTE-all patients PE-all patients P<0.0001 for all trends for increasing rates Trends in VTE in Hospitalized Cancer Patients Khorana AA et al. Cancer. 2007;110 (10):2339-2346.

  12. Hospitalization is a HIGH RISK Period for Venous Thromboembolism RiskOdds Ratio Hospitalization with surgery 21.72 Hospitalization without surgery 7.98 Cancer with chemotherapy 6.53 Prior central venous catheter 5.55 APC Resistance (FVL) 4.0 Prothrombin Gene Mutation 2.5 Homocysteinemia 2.5 Circulation 2003;107:I4-I8 Semin Thromb Haem 2002;26:3-13 Thrombosis Research 2007;119:391

  13. Venous Thromboembolism: Impact of Hospitalization or Surgery 63% Spencer F et al. Arch Intern Med. 2007;167:1471-1475

  14. VTE Epidemiology:Focused Opportunities For Prevention • Hospitalization and/or surgery account for 60% of VTE events and provide discrete opportunities to employ preventive strategies. • Recognizable risks unrelated to hospitalization/surgery (immobility, malignancy, fractures, etc) account for another 15-20% of VTE events. Focused interventions could reduce the burden of VTE by 50%

  15. Routine Use of Thromboprophylaxis Improves Outcomes In Surgery Patients Ctrl ProphylaxisRRR DVT 22% 9% 60% Overt PE 2% 1.3% 35% Fatal PE 0.8% 0.3% 63% Mortality 4.2% 3.2% 25% N Engl J Med. 1988;318:1162–1173.

  16. JCAHO Measures for DVT/PE Prevention(Part of SCIP) • Surgery patients with recommended prophylaxis ordered • Surgery patients who received appropriate prophylaxis within 24 hours prior to surgery to 24 hours after surgery 86% of Surgical Patients in U.S. Receive Recommended Prophylaxis

  17. Medical Patient: An Important Group Lindblad B et al. BMJ. 1991;302:709-711. Spencer F et al. Arch Intern Med. 2007;167:1471-1475

  18. No. Studies 95% CI 9 0.26-0.71 7 0.21-0.69 4 0.22-1.00 0.77-1.21 5 8 0.73-2.37 Anticoagulant Prophylaxis Reduces Symptomatic VTE in Hospitalized Medical Patients Total n (all 9 studies) = 19,958 Dentali F et al. Ann Intern Med 2007;146:278-88

  19. 0 30 60 90 Electronic Alerts Reduce DVT/PE Absence of DVT or PE in the Intervention Group and the Control Group 100 98 Intervention Group (34% received prophylaxis) 96 Freedom From DVT or PE (%) 94 41% reduction in DVT/PE Control Group(14% received prophylaxis) 92 P<0.001 90 0 Days Number at Risk Intervention Group 1255 977 900 853Control Group 1251 976 893 839 P<0.001 by log-rank test for the comparison of the outcome between groups at 90 days. *Interventions included UFH, LMWH, and mechanical prophylaxis. Data are Kaplan-Meier estimates. Kucher et al N Engl J Med. 2005;352:969-977.

  20. VTE Prophylaxis Rates Are Poor In At-Risk Medical Patients Burleigh E et al. Am J Health-Syst Pharm 2006;63(Suppl 6):S23-9, Goldhaber SZ et al. Am J Cardiol 2004;93:259-262, Yu H-T et al. Am J Health-Syst Pharm 2007;64:69-76, Amin A et al. Chest 2006;130(suppl):87S, Tapson VF et al. Blood 2003;102:Abstract #1154, Tapson VF et al. Chest 2007;[epub ahead of print], Cohen AT. Presented at the XXIst Congress of ISTH in Geneva, Switzerland July 8, 2007

  21. DVT Prevention Pending Quality Measures & Public Reporting • Prophylaxis in place within 24 hours of admit or risk assessment / contraindication justifying it’s absence • Same for critical care unit admit / transfers • Track preventable VTE

  22. Case of Mrs. S 68yo obese female with stage III ovarian cancer was admitted to the hospital with RLL pneumonia and sepsis…. VTE Risk was recognized Thromboprophylaxis was started What went wrong?

  23. Direct admission ED Potential Disruptions in Appropriate Prophylaxis May Occur During Transitions of Care Rehab Medical/Surgical • Numerous transition points where an order can be forgotten: admission, transfers, post-op, discharge. • Discontinuity in providers across care transitions Discharge Admission Respiratory/ICU SNF Surgical/ICU LTAC LTC Prophylaxis gaps may occur because: Home +/- home health ED, emergency department; ICU, intensive care unit; SNF, skilled nursing facility; LTC, long-term care; LTAC, long-term acute care.

  24. At-Risk Acutely Ill Medical Patients Have Unprotected Days In and Out of the Hospital Real-life thromboprophylaxis does not match length of stay1 • Duration of prophylaxis demonstrated to be effective in clinical trials is approximately 6-14 days • Possible gap between hospital admission and recognition of risk: nearly 2 days1,2 • 18% of DVT/PE events among acutely ill medical patients occurred after discharge3 7 6 6.1 5 Days 4 4.4 3 2 1 0 Length of prophylaxis Length of stay • Data on file, sanofi-aventis U.S. LLC. • Amin A et al. J. Thromb Haemost. 2007;130(suppl 4):87S. • Edelsberg J et al. Am J Heath-Syst Pharm. 2006;63(suppl):S16-S21

  25. Acute Care HospitalizationAge related Trends in Length of Stay 2005 Median LOS was 3-4 days Advance Data No. 385 + July 12, 2007

  26. National Trends In Average Length of Stay:Majority of Patients Are In Hospital for Fewer than 4 Days Average LOS 7.8 Days Average LOS 7.3 Days Average LOS 6.4 Days Average LOS 4.8 Days (57%) (36%) Vital Health Statistics, Advance Data No. 359 + July 8, 2005

  27. Disconnect Between Clinical Trials and Current Inpatient Population • 85% of patients are hospitalized for less than 7days

  28. Many VTE Events Occur Soon After Hospitalization/Surgery Median LOS = 4 Days Days after discharge/surgery Spencer F et al. Arch Intern Med. 2007;167:1471-1475

  29. Nursing Homes & VTE Risk • Attributable VTE risk = 13.3% • VTE Risk = 36 events/1000 person-years CharacteristicOdds Ratio95% CI Difficulty with behavior 10.26 2.09 - 50.4 Return from hospital 6.29 1.73- 22.8 Needs assistance with ADL 5.10 1.38- 18.9 Leibson et al. Mayo Clin Proc. 2008;83(2):151-157 & Heit et al Arch Intern Med 2002; 162:1245

  30. Inpatient prevention of VTE is not a dichotomous yes or no metric. Proper VTE prophylaxis requires evidence-based measures applied according to protocols used in randomized controlled trials. For pharmacological prophylaxis, this means ordering the right dose of the right medication at the right time for the proper duration (which may span the hospitalization and the early period after hospital discharge). Outpatient and inpatient VTE are coupled; they should no longer be placed in separate silos. Dr Samuel Z. Goldhaber Arch Intern Med. 2007;167:1451-1452

  31. Conclusions • VTE is common • A majority of VTE events occur in patients related to hospitalization or surgery. • Initial risk assessment and initiation of prophylaxis are important QI interventions that can reduce VTE. • As our healthcare system evolves (e.g. shorter hospitalizations & more outpatient interventions) we will need to change our strategies wherein DVT prophylaxis is not just delivered in the acute hospital setting.

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