Elsevier

The Lancet

Volume 371, Issue 9610, 2–8 February 2008, Pages 387-394
The Lancet

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Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study

https://doi.org/10.1016/S0140-6736(08)60202-0Get rights and content

Summary

Background

Information about the variation in the risk for venous thromboembolism (VTE) and in prophylaxis practices around the world is scarce. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study is a multinational cross-sectional survey designed to assess the prevalence of VTE risk in the acute hospital care setting, and to determine the proportion of at-risk patients who receive effective prophylaxis.

Methods

All hospital inpatients aged 40 years or over admitted to a medical ward, or those aged 18 years or over admitted to a surgical ward, in 358 hospitals across 32 countries were assessed for risk of VTE on the basis of hospital chart review. The 2004 American College of Chest Physicians (ACCP) evidence-based consensus guidelines were used to assess VTE risk and to determine whether patients were receiving recommended prophylaxis.

Findings

68 183 patients were enrolled; 30 827 (45%) were categorised as surgical, and 37 356 (55%) as medical. On the basis of ACCP criteria, 35 329 (51·8%; 95% CI 51·4–52·2; between-country range 35·6–72·6) patients were judged to be at risk for VTE, including 19 842 (64·4%; 63·8–64·9; 44·1–80·2) surgical patients and 15 487 (41·5%; 41·0–42·0; 21·1–71·2) medical patients. Of the surgical patients at risk, 11 613 (58·5%; 57·8–59·2; 0·2–92·1) received ACCP-recommended VTE prophylaxis, compared with 6119 (39·5%; 38·7–40·3; 3·1–70·4) at-risk medical patients.

Interpretation

A large proportion of hospitalised patients are at risk for VTE, but there is a low rate of appropriate prophylaxis. Our data reinforce the rationale for the use of hospital-wide strategies to assess patients' VTE risk and to implement measures that ensure that at-risk patients receive appropriate prophylaxis.

Introduction

Venous thromboembolism (VTE) is a common complication during and after hospitalisation for acute medical illness or surgery. Pulmonary embolism accounts for 5–10% of deaths in hospitalised patients, making VTE the most common preventable cause of in-hospital death.1, 2, 3, 4 In addition to the acute risk of mortality, VTE is associated with long-term risks of post-thrombotic syndrome5 and chronic thromboembolic pulmonary hypertension.6 These complications contribute substantially to patient morbidity and the cost of management.

Evidence-based consensus guidelines for VTE prophylaxis have been available for more than 15 years.7 Despite the existence of these guidelines, VTE prophylaxis remains underused.8, 9 Existing studies have assessed compliance with prophylaxis guidelines within defined institutions or countries,8, 10, 11, 12 but to date, the proportion of at-risk patients who should receive prophylaxis globally remains unknown.

We did the multinational, observational, cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study, a chart audit of medical and surgical patients in a large sample of hospitals worldwide. The study was designed to assess the number of patients at risk for VTE in the acute care hospital setting and to determine the proportion of these at-risk patients who received prophylaxis as recommended by the American College of Chest Physicians (ACCP) evidence-based consensus guidelines.1

Section snippets

Procedures

Hospitals were considered eligible for enrolment if they contained more than 50 beds, admitted patients for the treatment of medical illnesses and exacerbations of chronic diseases, and scheduled routine major surgical procedures. Non-acute and single specialty hospitals were excluded.

Hospitals were selected at random from authoritative lists of acute care hospitals in 32 participating countries. In the USA, a list of acute care hospitals from the American Hospital Association was used.13 The

Results

Between August, 2006, and January, 2007, eligible patients were enrolled from 358 hospitals across 32 countries that had completed the study within specified deadlines (Algeria, Australia, Bangladesh, Brazil, Bulgaria, Colombia, Czech Republic, Egypt, France, Germany, Greece, Hungary, India, Ireland, Kuwait, Mexico, Pakistan, Poland, Portugal, Romania, Russia, Saudi Arabia, Slovakia, Spain, Switzerland, Thailand, Tunisia, Turkey, United Arab Emirates, UK, USA, and Venezuela) in six continents.

Discussion

The data gathered show that, worldwide, more than half of all hospitalised patients are at risk for VTE, and that surgical patients seem to be at higher risk than are medical patients. Furthermore, only half of at-risk patients received an ACCP-recommended method of prophylaxis. Previous studies have reported overall VTE prophylaxis rates ranging from 13% to 64%.8, 9, 10, 11, 12 This variability is largely due to individual studies limiting their assessment to predefined populations (eg,

References (23)

  • R Otero et al.

    Use of venous thromboembolism prophylaxis for surgical patients: a multicentre analysis of practice in Spain

    Eur J Surg

    (2001)
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