Major Finding: Available information on the burden of VTE has been based on two epidemiologic studies and on limited data from hospital discharge surveys or analysis of provider claims databases.
Data Source: A workshop and a review of the literature by a national work group convened by the Centers for Disease Control and Prevention and the American Society of Hematology.
Disclosures: Dr. Raskob disclosed that he has received consulting fees from Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Pfizer, GlaxoSmithKline, Johnson & Johnson, Daiichi Sankyo, Sanofi-Aventis, and Takeda.
There is no shortage of clinical guidelines describing the risk factors for deep vein thrombosis and pulmonary embolism and how to effectively treat and prevent them.
What is lacking, a national work group has concluded, is any way to track whether those guidelines are being implemented.
Also missing is information about how such guidelines might affect the incidence of venous thromboembolism (VTE). These questions can be answered only through collection of data by a national surveillance program, according to Gary E. Raskob, Ph.D., and his colleagues.
The work group, convened by the Centers for Disease Control and Prevention and the American Society of Hematology, consisted of physicians, epidemiologists, and health care policy experts. Following a 1-day workshop, the group summarized the literature on the clinical impact of deep vein thrombosis (DVT) and pulmonary embolism (PE) in several areas of medicine, wrote Dr. Raskob, of the University of Oklahoma Health Sciences Center, Oklahoma City, and his coauthors (Am. J. Prev. Med. 2010; 38:S502-9).
The available information on the clinical and economic burden of VTE “has been based on two population-based epidemiologic studies and on limited data from hospital discharge surveys or analysis of healthcare provider claims databases,” the work group wrote.
Each year, about 900,000 cases of VTE occur in the United States. The risk of VTE increases with age, and is somewhat higher for men than for women (114 vs. 105/100,000). There are few data on whether DVT incidence varies by ethnic group, and available studies vary widely in methodology and conclusions.
A California patient discharge review that spanned 1991–1994 found an annual incidence among whites of 230/1 million population, compared with 293/1 million for blacks, 139/1 million for Hispanics, and 60/1 million for Asian/Pacific Islanders.
Most VTEs are associated with a recent hospitalization; therefore, the work group said, hospitalization is an opportune time to institute prevention measures and to educate patients on the risks of blood clots.
Among its recommendations, the work group suggested that the CDC:
▸ Establish a demographic picture of DVT and PE in the United States.
▸ Determine whether there are incidence differences among minorities, compared with white populations.
▸ Further define risk factors among various patient groups (pregnant patients, surgical patients, children, residents of long-term care facilities, and patients with a family history of VTE).
▸ Evaluate whether evidence-based preventive measures are being appropriately applied.
▸ Detect changes in the incidence of DVT and PE and relate these changes to any increase in the use of preventive measures.
The group also recommended that the CDC initiate a two-pronged national public awareness campaign, focusing on increasing overall understanding of the disorder and its risk factors, and encouraging patients who are about to undergo surgery or hospitalization to discuss the subject with their physicians.
My Take
Stop Underestimating VTE Risk
It's time for physicians and the public to take an in-depth look at this issue. Although at least four clinical treatment and prevention guidelines are available, they are not always employed in practice. We all know that everyone in the hospital should be receiving VTE prophylaxis, for example. Unfortunately, not everyone is getting it.
Several factors probably contribute to the problem. In some cases, we simply forget about VTE prevention. When a physician is dealing with acute problems in a very sick patient, VTE prevention might not be the first thing on that doctor's mind. Also, there are physicians who simply are not aware of the prevention guidelines, and so they don't implement them.
Finally, physicians who see discharged patients in the community—where 75% of VTEs occur—might not appreciate the importance of continuing prophylaxis after discharge. Physicians who don't provide care for patients in the hospital can go for years without seeing a clot, so they may underestimate the magnitude of the problem.
Franklin A. Michota, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.
