QJM Advance Access originally published online on October 15, 2007
QJM 2007 100(11):685-689; doi:10.1093/qjmed/hcm085
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The under use of thromboprophylaxis in older medical in-patients: a regional audit
From the 1Department of Medicine for the Elderly, St James's University Hospital, Leeds, 2Department of Medicine for the Elderly, York Hospital, York, 3Hull and York Medical School/Department of Health Science, University of York, York, UK, and 4Department of Medical Gerontology. Trinity Centre of Health Sciences, St James's Hospital, Dublin, Eire
Address correspondence to Dr A. South, Department of Medicine for the Elderly, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK. email: alsouthuk{at}yahoo.co.uk
Received 23 March 2007 and in revised form 4 July 2007
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Background: The risk of venous thromboembolism (VTE) among medical in-patients increases with age. Thromboprophylaxis using low-molecular-weight heparin can reduce the incidence by 50%, but anecdotally is under-used in medical patients, particularly the elderly.
Aim: To examine prescribing practice for thromboprophylaxis in elderly in-patients in the Yorkshire region.
Design: Regional audit of medical records and drug charts.
Methods: A simultaneous audit was done of all medical in-patients >75 years on 30 wards in 10 hospitals. Guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) on the use of thromboprophylaxis were used as the standard. Data were collected on contraindications and/or indications for thromboprophylaxis and the type of prophylaxis used.
Results: Of 601 patients studied (mean age 84.6 years), 117 (19.5%) had indications for thromboprophylaxis with no contraindications. Of these 117, 34 (29%) were receiving prophylaxis as per guidelines. There was more than one indication for thromboprophylaxis in 17% of those left untreated. The mean age of those receiving therapy was similar to those not receiving it (84.0 vs. 84.5 years, p = 0.66, t-test). Elderly in-patients on medical wards were more likely to receive appropriate treatment than those on geriatric wards (43% vs. 23%, p = 0.03, 
2 test).
Discussion: Thromboprophylaxis is under-used in older medical in-patients, despite their increased risk of VTE, particularly on geriatric wards. Greater consideration by doctors attending to older medical patients is needed if VTE is to be prevented.
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Introduction |
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Deep vein thrombosis (DVT) is common, has many risk factors and may cause few or no symptoms. Pulmonary embolism (PE) is a potentially fatal complication, contributing to approximately 10% of all hospital deaths.1 Older patients (i.e. >65 years) have a higher mortality, both in hospital and at 1 year, when compared to those aged <40 years (21% and 39% vs. 2% and <10%, respectively).2 It is reported that 90% of PEs result from asymptomatic DVTs.3
The risk of venous thromboembolism (VTE) is increased 10-fold in patients who are hospitalized after trauma, surgery or immobilizing medical illness.4 The extent of the problem in medical in-patients appears to be under-appreciated. In a study by Goldhaber et al. in 2000, 54% of hospitalized patients who had developed symptomatic VTE were general medical or non-surgical oncology in-patients.5 Meta-analysis of randomized trials estimates the risk of DVT in hospitalized medical patients receiving no thromboprophylaxis to be as high as 20%,6 and this excludes patients with acute myocardial infarction and ischaemic stroke. Thromboprophylaxis, using low-dose unfractionated heparin (LDUH) or low molecular weight heparin (LMWH), is effective in preventing venous thromboembolism and is recommended by both UK and US guidelines.
The most frequently used guidelines for the prophylaxis of VTE in the UK are the National Clinical Guidelines from the Scottish Intercollegiate Guidelines Network (SIGN)4 published in 2002 and reviewed in 2005 (Table 1). In addition to specific guidelines with respect to patients with acute coronary syndromes and stroke, they recommend that ‘in general medical patients who are immobilized in hospital due to acute illness, especially those with heart failure, respiratory failure infections, diabetic coma, inflammatory bowel disease, nephrotic syndrome, or in intensive care, prophylaxis of VTE with low-dose unfractionated heparin (LDUH) or LMWH should be considered.’
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The American College of Chest Physicians (ACCP) also published guidelines for the prophylaxis of venous thromboembolism in 2004.7 The recommendations from these guidelines regarding medical patients differ slightly from those of SIGN with respect to recommending therapy for some non-immobilized medical patients, particularly patients with congestive heart failure and severe respiratory disease. The guidelines recommend that ‘patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, including active cancer, previous VTE, sepsis, acute neurological disease, or inflammatory bowel disease’ should receive prophylactic LDUH or LWMH’. It is not clear to what extent this will increase the proportion of patients suitable for thromboprophylaxis.
In situations where anticoagulants are contraindicated or not proven to be effective, such as following acute stroke, both guidelines recommend the use of mechanical means of prophylaxis such as anti-embolism stockings, although both acknowledge the relative paucity of evidence for such methods.
Despite the availability of these guidelines, experience suggests thromboprophylaxis is under-used on medical and elderly wards. Our aim was to determine prescribing practice to at-risk in-patients within the Yorkshire Region.
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Methods |
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An audit was undertaken over 48 hours during a 2-week period in ten Yorkshire hospitals serving a population of 3.5 million people. Data were collected on all in-patients aged
75 years on a representative selection of 30 wards (General Medical and Geriatric), by members of the Geriatric Registrars Research and Audit Network Yorkshire (GRRANY). All members of GRRANY are physicians who are either undergoing or have completed specialist training in Geriatrics and General internal Medicine. Records on all patients in selected geriatrics wards and all subjects aged 75 years on selected medical wards were audited, using the 2002 National Clinical Guidelines from SIGN as the audit standard.4 Patients’ medical records and drug charts were reviewed. Information was gathered on age, gender and contra-indications for prophylaxis. Data for specified indications for prophylaxis were also collected. Data with respect to immobility and type of prophylaxis used were also collected (Table 2) in each case and recorded on a proforma. Specialist Registrars were asked about their awareness, and the availability, of guidelines in their trust. The Local Research Ethics committee was consulted in advance of the audit commencing, and on review, ethics approval was deemed unnecessary. The audit was completed through the audit procedures pertaining to each trust. Anonymized data were collated centrally and analysed using a computerized statistics package. Mean ages of patients were compared using t-tests; proportional data were compared using Pearson's 2 and Fisher's exact tests.
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Results |
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Records for 601 patients (median 84.6 years, 64% female), were evaluated (Figure 1). Of these, 236 were not felt to require treatment either because: (i) their medical condition was not considered to be an increased risk for venous thromboembolism by the SIGN guidelines; (ii) they were receiving end of life palliative care; or (iii) they were already undergoing full anticoagulation for other reasons. A further 22 had absolute contraindications to anticoagulation, and 226 had medical indications for thromboprophylaxis but were not felt by investigators to be immobile. The remaining 117 (19%) were felt to meet criteria for thromboprophylaxis either for LMWH/LDUH in medically unwell patients, or anti-embolism stockings for patients following acute stroke. Of note, if mobile patients with heart failure and respiratory failure were included in the group appropriate for thromboprophylaxis, as recommended in the ACCP guidelines, then the number of those considered suitable for treatment would increase from 117 patients (19%) to 165 patients (27%).
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Eighty-two (70%) of the 117 patients suitable for thromboprophylactic therapy under the SIGN guidelines were on Geriatrics wards, and 35 were on General Medical wards. Ninety-eight (84%) patients had one absolute indication for thromboprophylaxis; the remaining 19 (16%) had two indications.
Only 34 (29%) patients with indications received appropriate thromboprophylactic treatment; Table 2 outlines the differences between those with indications who received thromboprophylaxis and those who did not. No difference was found in prescribing related to age or gender, however, elderly in-patients on Medical wards with indications for thromboprophylaxis were more likely to have received appropriate treatment, than were patients on Geriatric wards (43% vs. 23%, 2 = 4.6, df = 1, p = 0.03). Immobilized patients with heart failure, respiratory failure and infections were all significantly less likely than others to receive thromboprophylaxis (Table 2).
In the hospitals studied, LMWH had completely superseded all other methods of pharmaceutical thromboprophylaxis. While some patients were receiving treatment dose anticoagulation using intravenous unfractionated heparin, no patient received LDUH as thromboprophylaxis. There were 29 patients identified with a diagnosis of acute stroke: 23 had acute stroke as a sole indication for thromboprophylaxis, of whom only 6 (26%) were wearing anti-embolism stockings at the time of audit.
Specialist Registrars were aware of thromboprophylaxis guidelines in just 5/10 hospitals, with guidelines readily available on wards in only two trusts. Information for patients regarding thromboprophylaxis was not available on any ward.
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Discussion |
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Compliance with national guidelines as to the use of thromboprophylaxis in elderly in-patients is poor. This is particularly true on specialist geriatric wards. Fewer than one third of our patients received treatment, even though they often had multiple indications, and there is good evidence that older people are at greater risk of venous thromboembolism.8
The study was designed to reflect actual practice across a large region of the UK. Although it is a regional study, we feel that its results are likely to reflect UK practice in general. They are similar to those of Rashid and colleagues, who, in their observational study of 1128 medical patients in two London teaching hospitals, also found that only 29% of patients deemed at moderate to high risk of VTE received any form of prophylaxis.9 The intention of the study was to carry out simultaneous audit in all hospitals in the region over 48 h. However, for reasons of resources and time, this meant that not every medical and geriatric ward in every hospital could be audited. The wards chosen for audit were selected by physicians familiar with the hospitals as being representative of the hospital, and to further avoid patient selection bias, every patient present on selected wards on the days of audit was studied. The general medical wards were selected as those taking a significant proportion of admissions of older people. The audit tool used was trialled in one hospital (York Hospital) before use in the regional audit. While it is possible that ward selection may have influenced results, there were similar differences in use of thromboprophylaxis between geriatrics and medical units across the region, and we feel that such an influence is unlikely.
We had difficulty in determining which patients were immobilized ‘due to acute illness’ as described in the guidelines, as opposed to those who were chronically immobile. However, as it is the fact of immobility rather than the cause that is likely to predispose to venous thromboembolism, we made no distinction when recruiting patients. The additional risk of thromboembolism for patients with long-term immobility admitted to hospital with acute illness has never been studied to our knowledge, and would merit investigation.
We found no conclusive reasons for reluctance in administering thromboprophylaxis to older people. One potential reason for reluctance to use thromboprophylaxis is that the therapy would be considered unpleasant and an added burden or risk to patients. There is no empirical evidence we can find for this assumption, but when asked by Noble and colleagues, in-patients receiving palliative care for advanced cancer felt that thromboprophylaxis with low molecular weight heparin was acceptable, and in fact had a positive impact on their quality of life.10 Noble also commented as to some dissatisfaction among these patients at to their lack of involvement in such decisions. This may suggest that we should also examine our practise and involve patients more, where possible.
The issue of the use of anti-platelet agents was not addressed in this audit. Neither the SIGN nor the ACCP guidelines make recommendations as to the use of such agents in the prophylaxis of venous thromboembolism, although clearly their role in the prevention of further arterial thrombosis in acute coronary syndromes and ischaemic stroke is well established. It may be that the concurrent use of aspirin or other anti-platelet agents discouraged physicians from using concomitant heparin, although the guidelines do not consider this a contraindication to the routine use of either LDUH or LMWH in prophylactic doses, there is little evidence for the efficacy of anti-platelets in prophylaxis of VTE in medical patients and we have no evidence from the audit that physicians took this view.
Even where patients had more than one indication for therapy, less than one third actually received thromboprophylaxis. Indeed, patients with more than one indication for therapy were not more likely to receive appropriate thromboprophylaxis than those with only one. This suggests a lack of awareness of the importance of the therapy in older people. What was reasonably consistent between hospitals was the shortage of formal staff training regarding the importance of thromboprophylaxis for medical patients, and the absence of information available to clinical staff and patients on the risks and prophylaxis of venous thromboembolism. Participating investigators, all practicing specialist registrars in geriatrics and general internal medicine, were aware of formal thromboprophylaxis guidelines in only half of the ten hospitals studied, and in those five hospitals, not all of the participating registrars were aware of guidelines. Historically, prevention of venous thromboembolism may have received less emphasis on medical than on cardiac, surgical or orthopaedic wards. This may indicate that the absence of specific training and visible reminders and information sources on medical wards may have affected both awareness of the importance and the use of thromboprophylaxis. We suggest that posters and information sheets should be present on all medical wards in a similar manner to those outlining cardiopulmonary resuscitation or hand washing guidelines, and that studies of VTE prophylaxis should be introduced into medical departmental training and audit cycles.
Awareness needs to be raised amongst staff and patients by the dissemination and implementation of guidelines and information. The long awaited guidelines from the National Institute of Clinical Excellence (NICE) expected in 2007 will hopefully further help to raise the profile of this important topic.
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References |
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5. Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than withholding treatment. Chest (2000) 118:1680–4.[CrossRef][Web of Science][Medline]
6. Mismetti P, Laporte-Simitsidis S, Tardy B, Cucherat M, Buchmuller A, Juillard-Delsart D, Descousus H. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: meta-analysis of randomised clinical trials. Thromb Haemost (2000) 83:14–19.[Web of Science][Medline]
7. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest (2004) 126:338–400.[CrossRef]
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9. Rashid ST, Thursz MR, Razvi NA, Voller R, Orchard T, Rashid ST, Shlebak AA. Venous thromboprophylaxis in UK medical inpatients. J R Soc Med (2005) 98:507–12.
10. Noble SIR, Nelson A, Turner C, Finlay IG. Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative study. Br Med J (2006) 322:577–9.
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