Epidemiology of vte in the us the opportunity for prevention looms large l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 33

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


  • 117 Views
  • Uploaded on
  • Presentation posted in: General

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

Download Presentation

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

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Epidemiology of vte in the us the opportunity for prevention looms large l.jpg

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


Objectives l.jpg

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


Case of mrs s l.jpg

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…


Vte prevention a national quality priority 2008 surgeon general s report call to action l.jpg

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


Venous thromboembolism is common annual u s event rates l.jpg

Venous Thromboembolism Is Common(Annual U.S. Event Rates)

  • Blood 2005; 106:Abstract 910 ArchIntMed 2008; 168:425


Vte is a common cause of death in the united states l.jpg

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


Vte incidence is increasing l.jpg

VTE Incidence is Increasing

J G IM 2006; 21:722


Vte risk increases with age age related vte attack rates per 100 000 population l.jpg

VTE Risk Increases with Age(Age-Related VTE Attack Rates per 100,000 population)

Spencer et al. J General Internal Medicine (2006); : 722-727


Overall attributable risks are common in patients with vte l.jpg

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


Strong association between cancer venous thromboembolism l.jpg

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)


Slide12 l.jpg

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.


Hospitalization is a high risk period for venous thromboembolism l.jpg

Hospitalization is a HIGH RISK Period for Venous Thromboembolism

RiskOdds Ratio

Hospitalization with surgery21.72

Hospitalization without surgery7.98

Cancer with chemotherapy6.53

Prior central venous catheter5.55

APC Resistance (FVL)4.0

Prothrombin Gene Mutation2.5

Homocysteinemia2.5

Circulation 2003;107:I4-I8 Semin Thromb Haem 2002;26:3-13 Thrombosis Research 2007;119:391


Venous thromboembolism impact of hospitalization or surgery l.jpg

Venous Thromboembolism: Impact of Hospitalization or Surgery

63%

Spencer F et al. Arch Intern Med. 2007;167:1471-1475


Vte epidemiology focused opportunities for prevention l.jpg

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%


Routine use of thromboprophylaxis improves outcomes in surgery patients l.jpg

Routine Use of Thromboprophylaxis Improves Outcomes In Surgery Patients

CtrlProphylaxisRRR

DVT22% 9%60%

Overt PE2% 1.3%35%

Fatal PE0.8%0.3%63%

Mortality4.2%3.2%25%

N Engl J Med. 1988;318:1162–1173.


Slide17 l.jpg

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


Medical patient an important group l.jpg

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


Anticoagulant prophylaxis reduces symptomatic vte in hospitalized medical patients l.jpg

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


Electronic alerts reduce dvt pe l.jpg

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 Group1255977900853Control Group1251976893839

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.


Vte prophylaxis rates are poor in at risk medical patients l.jpg

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


Dvt prevention pending quality measures public reporting l.jpg

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


Case of mrs s23 l.jpg

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?


Potential disruptions in appropriate prophylaxis may occur during transitions of care l.jpg

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.


At risk acutely ill medical patients have unprotected days in and out of the hospital l.jpg

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


Acute care hospitalization age related trends in length of stay l.jpg

Acute Care HospitalizationAge related Trends in Length of Stay

2005 Median LOS was 3-4 days

Advance Data No. 385 + July 12, 2007


Slide28 l.jpg

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


Disconnect between clinical trials and current inpatient population l.jpg

Disconnect Between Clinical Trials and Current Inpatient Population

  • 85% of patients are hospitalized for less than 7days


Many vte events occur soon after hospitalization surgery l.jpg

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


Nursing homes vte risk l.jpg

Nursing Homes & VTE Risk

  • Attributable VTE risk = 13.3%

  • VTE Risk = 36 events/1000 person-years

    CharacteristicOdds Ratio95% CI Difficulty with behavior10.262.09 - 50.4 Return from hospital 6.291.73- 22.8 Needs assistance with ADL 5.101.38- 18.9

Leibson et al. Mayo Clin Proc. 2008;83(2):151-157 & Heit et al Arch Intern Med 2002; 162:1245


Slide32 l.jpg

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


Conclusions l.jpg

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.


  • Login