Chest
Volume 132, Issue 3, September 2007, Pages 936-945
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ORIGINAL RESEARCH
VENOUS THROMBOEMBOLISM
Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients: Findings From the International Medical Prevention Registry on Venous Thromboembolism

https://doi.org/10.1378/chest.06-2993Get rights and content

Background

Evidence-based guidelines recommend that acutely ill hospitalized medical patients who are at risk of venous thromboembolism (VTE) should receive prophylaxis. Our aim was to characterize the clinical practices for VTE prophylaxis in acutely ill hospitalized medical patients enrolled in the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE).

Methods

IMPROVE is an ongoing, multinational, observational study. Participating hospitals enroll the first 10 consecutive eligible acutely ill medical patients each month. Patient management is determined by the treating physicians. An analysis of data on VTE prophylaxis practices is presented.

Results

From July 2002 to September 30, 2006, 15,156 patients were enrolled from 52 hospitals in 12 countries, of whom 50% received in-hospital pharmacologic and/or mechanical VTE prophylaxis. In the United States and other participating countries, 52% and 43% of patients, respectively, should have received prophylaxis according to guideline recommendations from the American College of Chest Physicians (ACCP). Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis. Practices varied considerably. Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively). Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with low-molecular-weight heparin used most frequently in other participating countries (40%). There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively).

Conclusions

Our data suggest that physicians' practices for providing VTE prophylaxis to acutely ill hospitalized medical patients are suboptimal and highlight the need for improved implementation of existing evidence-based guidelines in hospitals.

Section snippets

Materials and Methods

Patient recruitment into the IMPROVE registry took place between July 2002 and September 2006. In contrast to randomized, controlled, clinical studies, no experimental interventions were imposed. Patient management was determined by the treating physicians, and hence the data reflect a real-world approach to VTE prevention.

Hospital and Patient Characteristics

Between July 2002 and September 2006, 15,156 patients were enrolled in the study from 52 hospitals in 12 countries (Australia, Brazil, Canada, Columbia, France, Germany, Italy, Japan, Spain, the United Kingdom, the United States, and Venezuela). Ten countries had three or more active sites, and 2 countries had two active sites each. Of the 52 hospitals participating, 15% are nonprofit public institutions, 15% are for-profit institutions, 65% are nonprofit private institutions, and the status of

Discussion

Half of acutely ill hospitalized medical patients who were enrolled in the IMPROVE study received either mechanical or pharmacologic VTE prophylaxis. Half of patients in the United States and almost half of those in other countries met the criteria of the ACCP guidelines for patients who should receive prophylaxis.10 Of these, 6 of every 10 patients actually received prophylaxis. A similar proportion of patients who would have been eligible for enrollment in the MEDENOX, PREVENT, or ARTEMIS

Appendix 1

The IMPROVE study is overseen by a medical advisory board of clinicians. Further information about the registry can be found at http://www.outcomes-umassmed.org/improve/.

Appendix 2

ACKNOWLEDGMENT

The authors thank the physicians and study coordinators participating in the IMPROVE study, and Tim Norris for providing editorial assistance in the preparation of this manuscript.

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    All authors significantly contributed to the concept and design of the study, the interpretation of data, and critical revision of the manuscript. All authors approved the final version of the manuscript. Dr. FitzGerald performed all statistical analyses of data from IMPROVE.

    IMPROVE is supported by an unrestricted educational grant from sanofi-aventis to the Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA.

    Dr. Bergmann has received honoraria from Sanofi-Aventis and AstraZeneca. Dr. Froehlich has served as a consultant for Sanofi-Aventis. Dr. Kakkar has received consultancy/research funding from Sanofi-Aventis, sponsors of the IMPROVE registry. Dr. Merli has participated in research studies with AstraZeneca, Sanofi-Aventis, and Boehringer Ingelheim; has served on advisory boards with Bayer, Bacchus Scientific, AstraZeneca, and Sanofi-Aventis; and has been a speaker for AstraZeneca and Sanofi-Aventis. Dr. Pini has received fees from Sanofi-Aventis for being a member of the IMPROVE advisory board, and for conducting clinical studies and for lectures. Dr. Spencer has been a consultant for and has received a grant from Sanofi-Aventis. Dr. Spyropoulos has received grants/research support from and has been a consultant for Sanofi-Aventis and Astra-Zeneca. Dr. Tapson has received grants/research support from and has been a consultant for Sanofi-Aventis. Drs. Decousus, Chong, Monreal, Zotz, Pavanello, Turpie, Nakamura, Piovella, FitzGerald, and Anderson have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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