Factors Influencing Prescribers' Decision for Extending Venous Thromboembolism Prophylaxis in the Medical Patient Population following Hospitalization

Abstract

Introduction Venous thromboembolism (VTE) prophylaxis during hospitalization has clearly defined metrics for risk stratification and practice policy employed to ensure processes of adherence. However, acceptance for practice or even the level and timeline of risk is less clear during the immediate time after hospitalization. With emerging new oral anticoagulant agents, data are available that may influence prescribing in the outpatient setting following hospitalization. A survey was created to determine the level of acceptance or influences for practice surrounding continuation of anticoagulation following hospitalization.

Methods This study was designed as a single-center survey of hospitalist and family medicine physician to assess influences to the physician's impression for risk of VTE prophylaxis and knowledge of therapy options.

Results Physicians reported depending heavily on medical center protocols for determining anticoagulation at hospital discharge. Prescribing postdischarge anticoagulation was reported to be affected by lack of comfort with prescribing oral medications and concerns with risk of bleeding for all types of anticoagulation outweighing the perceived benefit. Additionally, the decision whether to prescribe these medications at discharge was reported to be related to perceived cost and other patient barriers such as concerns over route of administration.

Conclusion Concerns for bleeding were an influence and likely resulted in shorter duration for VTE prophylaxis being prescribed posthospitalization.

Keywords

VTE prophylaxis - venous thromboembolism prophylaxis - physician influences

Publication History

Received: 20 March 2020

Accepted: 11 August 2020

Article published online:
11 September 2020

• References

• 1 Spyropoulos AC, Raskob GE. New paradigms in venous thromboprophylaxis of medically ill patients. Thromb Haemost 2017; 117 (09) 1662-1670
• 2 Rosenberg D, Eichorn A, Alarcon M, McCullagh L, McGinn T, Spyropoulos AC. External validation of the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for medical patients in a tertiary health system. J Am Heart Assoc 2014; 3 (06) e001152
• 3 Germini F, Agnelli G, Fedele M. , et al. Padua prediction score or clinical judgment for decision making on antithrombotic prophylaxis: a quasi-randomized controlled trial. J Thromb Thrombolysis 2016; 42 (03) 336-339
• 4 Cohen AT, Spiro TE, Büller HR. , et al; MAGELLAN Investigators. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med 2013; 368 (06) 513-523
• 5 Spyropoulos AC, Ageno W, Albers GW. , et al; MARINER Investigators. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Engl J Med 2018; 379 (12) 1118-1127
• 6 Goldhaber SZ, Leizorovicz A, Kakkar AK. , et al; ADOPT Trial Investigators. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med 2011; 365 (23) 2167-2177
• 7 Miao B, Chalupadi B, Clark B. , et al. Proportion of US hospitalized medically ill patients who may qualify for extended thromboprophylaxis. Clin Appl Thromb Hemost 2019; 25: 1076029619850897
• 8 Office of the Surgeon General, National Heart, Lung, and Blood Institute. The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville, MD: Office of the Surgeon General (US); 2008
• 9 Cohen AT, Tapson VF, Bergmann JF. , et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371 (9610): 387-394
• 10 Cohen AT, Huang W, Harrington RA. , et al. Prevalence of major medical illnesses associated with venous thromboembolism risk in US hospitals. Poster presented at International Society on Thrombosis and Haemostasis 2017 Congress; July 8–13, 2017; Berlin, Germany:
• 11 Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146 (04) 278-288
• 12 Cave B, Hough A, Dobesh PP. Extended venous thromboembolism prophylaxis in medically ill patients. Pharmacotherapy 2018; 38 (06) 597-609
• 13 Amin AN, Varker H, Princic N, Lin J, Thompson S, Johnston S. Duration of venous thromboembolism risk across a continuum in medically ill hospitalized patients. J Hosp Med 2012; 7 (03) 231-238
• 14 Kahn SR, Lim W, Dunn AS. , et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, suppl) e195S-e226S
• 15 Cohen AT, Harrington RA, Goldhaber SZ. , et al; APEX Investigators. Extended Thromboprophylaxis with betrixaban in acutely ill medical patients. N Engl J Med 2016; 375 (06) 534-544
• 16 Gibson CM, Korjian S, Chi G. , et al; APEX Investigators. Comparison of fatal or irreversible events with extended-duration betrixaban versus standard dose enoxaparin in acutely ill medical patients: an APEX trial substudy. J Am Heart Assoc 2017; 6 (07) e006015
• 17 Gibson CM, Nafee T, Yee MK. , et al. Symptomatic event reduction with extended-duration betrixaban in acute medically ill hospitalized patients. Am Heart J 2018; 198: 84-90
• 18 Barbar S, Noventa F, Rossetto V. , et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 2010; 8 (11) 2450-2457
• 19 Woller SC, Stevens SM, Jones JP. , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med 2011; 124 (10) 947-954.e2
• 20 Gibson CM, Spyropoulos AC, Cohen AT. , et al. The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification. TH Open 2017; 1 (01) e56-e65
• 21 Doyle E. Extended VTE prophylaxis: reducing risk in post-discharge patients. Today's Hospitalist. 2019 . Available at: https://www.todayshospitalist.com/vte-risk-factors-post-discharge/ . Accessed May 26, 2020
• 22 Schellong SM, Kaiser J, Bramlage P. Continuation of venous thromboembolism prophylaxis after hospital discharge into the outpatient setting: the ACCEPT study. J Thromb Thrombolysis 2015; 39 (02) 173-178
• 23 Nadarajan K, Balakrishnan T, Ling Yee M. , et al. The attitudes and beliefs of doctors towards deprescribing medications. Proceedings of Singapore Healthcare 2018; 27 (01) 41-48