PHYSICIAN PRACTICES IN THE MANAGEMENT OF VENOUS THROMBOEMBOLISM - A COMMUNITY-WIDE SURVEY

Although there is a broad consensus on the optimum approach to the management of venous thromboembolism, there are few data from which to assess the extent of compliance with these recommendations. A community-wide study was therefore conducted in 16 short-stay hospitals in central Massachusetts to assess the clinical management of venous thromboembolism. Based on validated discharge diagnostic codes, there were 1231 clinically recognized cases of venous thromboembolism, 0.8% of 148,730 discharges in the 18-month period from July 1, 1988, to December 31, 1989. Eighty-one percent of study patients were admitted with signs or symptoms of acute venous thromboembolism. Ninety-seven percent of patients were treated with either heparin, warfarin, or inferior vena caval filter. Intravenous heparin was given to 89% of patients (mean bolus 6674 IU; mean duration 6.6 days). After heparin administration, there was a mean delay of 2.3 days in starting warfarin. Assuming a corresponding decrease in the length of hospital stay, appreciable cost savings could have been realized by earlier start of oral anticoagulation. An inferior vena cava filter was placed in 14% of patients. There was a clinically recognized in-hopsital recurrence of venous thromboembolism during treatment in 2% of patients. Despite a slightly lower rate of compliance with recommended treatment regimens in nonteaching hospitals, and despite less frequent use of the inferior vena cava filter, there was no significant difference in the rate of in-hospital recurrence of clinically recognized venous thromboembolism in 10 nonteaching hospitals compared with six teaching hospitals. Short-term patient outcomes observed in this community-wide study appear similar to those reported in controlled clinical trials in major academic health centers. Although long-term outcomes are uncertain in these patients, it appears that further reduction in the morbidity and mortality rates of venous thromboembolism may best be achieved by providing outpatient prophylaxis for individuals at continuing risk for venous thromboembolism.