WASHINGTON — In response to physician groups concerned about the high incidence of deep vein thrombosis and pulmonary embolism, Acting Surgeon General Steven K. Galson has issued a Call to Action statement.
In concert with the statement, which was released at the second annual meeting of the Venous Disease Coalitiion, the National Heart, Lung, and Blood Institute has awarded 5 years' worth of funding to eight research groups investigating venous thromboembolism treatments and prevention. Ongoing studies include a multicenter, randomized clinical trial of genotype-guided dosing of warfarin therapy, which is currently the most commonly used treatment for prophylaxis of recurrent venous thromboembolism, according to Dr. Elizabeth Nabel, director of clinical research at the NHLBI.
The major push to address the rising incidence of DVT and PE dates to a 2006 meeting betweeen former Surgeon General Richard H. Carmona and advocates. As a member of the Coalition to Prevent DVT, Dr. Frank Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic, spoke on public advocacy at that meeting.
“Hospitalists will play a pivotal role in the success of this Call to Action,” Dr. Michota said. “This is where hospitalists have an opportunity to develop, encourage, and pull through the systems of care that will guarantee all patients at risk for DVT are identified and that those found to be at risk will receive evidence-based methods of prophylaxis.”
Dr. Michota, medical editor-in-chief for Hospitalist News, added that he believes hospitalists are “more focused on this issue than any other specialty, including pulmonologists and cardiologists. Venous thromboembolism is one of the hospitalist's clinical core competencies.”
Hospitalists have been instrumental in the development of “reminder systems, preprinted order sheets, and multidisciplinary protocols so that no patient falls through the cracks in regards to DVT prevention,” he observed.
Further, there are new incentives to ensure that more hospitalized patients receive appropriate prophylaxis.
As of Oct. 1, 2008, any DVT or PE acquired during an inpatient stay in association with total knee and hip replacement procedures will have “payment implications,” according to the Centers for Medicare and Medicaid Services (HOSPITALIST NEWS, August 2008, p. 1).
Just how many patients are affected annually by venous thromboembolism is unclear. Without an autopsy, many fatal cases—perhaps as many as 50%—are misclassified as myocardial infarctions.
According to Dr. Roy S. Silverstein, chair of the committee of government affairs for the American Society of Hematology, the disease affects almost 1 million Americans annually, and “the estimated number of deaths from PE is higher than the combined number of deaths from breast cancer, HIV disease, and motor vehicle crashes.”
Dr. Galson put PE- or DVT-related deaths at 100,000 annually, with 350,000-600,000 Americans contracting DVT or PE each year.
The American Heart Association estimated the incidence of venous thromboembolism to be 250,000 to 2 million cases per year (Circulation 2002;106:1436). Meanwhile, upcoming studies put the annual number of cases somewhere in between those estimates.
The risk for DVT is known to be greatest among hospitalized spinal cord injury patients. Among those who do not receive VTE prophylaxis, the risk of developing a deep vein thrombosis (DVT) is 60%-80%.
Without VTE prophylaxis, the DVT risk is 40%-60% among hip and knee surgery patients, 20%-40% among patients undergoing major general surgery or gynecologic procedures, and 10%-20% for patients with acute illnesses like pneumonia.
“There is now a public acknowledgment that this is a very significant health care issue that deserves attention from multiple facets of the medical community,” Dr. Thomas Wakefield, head of vascular surgery at the University of Michigan, Ann Arbor said in an interview.
“We've known for a long time that (DVT and PE are) significant problems; however, since the conditions don't belong to one group or another and span so many specialties, it has been difficult to mobilize and raise awareness.”
Dr. Wakefield noted that the NHLBI initiative is an excellent start, but additional studies are needed, including studies of newer drugs and pharmacologic therapies with fewer adverse effects and interactions, and less need for monitoring than has warfarin.
Among the other studies worthy of consideration are investigations of short- and long-term outcomes associated with more aggressive interventions for DVT and PE. One such study, which has been funded by the National Institutes of Health and is slated to start soon, will compare pharmacomechanical thrombolysis plus standard anticoagulation to standard anticoagulation alone for the treatment of significant proximal venous thrombosis.
Booklets Focus on DVT Prevention
Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement is a 60-page booklet that includes case studies and is “designed to help hospitals and clinicians implement processes to prevent dangerous blood clots,” according to Dr. Carolyn Clancy, director of the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality, which published the booklets.