Venous thromboembolism is underdiagnosed, undertreated

Venous thromboembolism (VTE) is a common, potentially deadly, yet mostly preventable condition, with an estimated average annual incidence rate of more than 1 per 1,000. Furthermore, the incidence rate is significantly higher in adults age 75 and older, as many as 6 per 1,000.

These are only estimates, though. The true incidence of VTE—which is comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE)—is not known and likely underestimated.

“Currently, there is no national surveillance for VTE, so the precise number of people affected by VTE is unknown,” wrote scientists from the Centers for Disease Control and Prevention (CDC) in American Journal of Preventive Medicine. “[B]ecause of the difficulty in documenting DVT and PE, the limitations of administrative databases, and the regional and racial specificity of community-based studies, VTE may be vastly under-reported.”

Up to two-thirds of all VTE events in outpatients occur after hospitalization, surgery, or nursing home residence, but many of these cases of health care-associated VTE (HA-VTE) could be prevented.

“Recent analyses have shown that as many as 70% of HA-VTE cases are preventable through appropriate prophylaxis, yet reports suggest that fewer than half of hospital patients receive VTE prophylaxis in accordance with accepted evidence-based guidelines,” wrote many of the same CDC scientists in Journal of Hospital Medicine. “Appropriate prevention of HA-VTE can result in a significant reduction in overall VTE occurrence, thereby decreasing health care burden and unnecessary deaths.”

“Future research should be directed towards identification of the optimal targets for VTE prophylaxis,” wrote John A. Heit, MD, of the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, in Nature Reviews Cardiology.

“Groups currently considered to be at high risk of VTE, such as all patients undergoing hip or knee replacement surgery, include few individuals who would experience VTE in the absence of prophylaxis,” Dr. Heit explained. “The requirement is to identify the individuals within these groups who are at high risk of incident or recurrent VTE, who would benefit most from primary or secondary prophylaxis, thereby minimizing the risk of bleeding complications incurred by treatment of those at low risk.”

In that regard, the CDC began the Healthcare-Associated VTE Prevention Challenge in November 2015 to identify, highlight, and reward hospitals, managed care organizations, and hospital networks that implemented innovative, effective, and sustainable strategies to prevent HA-VTE.

Subsequently, the Agency for Healthcare Research and Quality (AHRQ) released “Preventing Hospital-Associated Venous Thromboembolism:A Guide for Effective Quality Improvement”—a peer-reviewed guide based on VTE quality improvement projects undertaken at the University of California, San Diego Medical Center and Emory University Hospitals. AHRQ developed this guide to help quality improvement efforts for VTE prevention in order to reduce patient risks, costs, morbidity, and mortality.

Additional VTE information:

• VTE recurs frequently—about 30% of patients with VTE have a recurrence within 10 years. Recurrence is particularly frequent in the first 6 to 12 months after the initial event.

• Risk of premature death among patients with symptomatic PE is 18-fold higher than that of patients with DVT alone.

• VTE risk is higher in patients with cancer—nearly 20% of all incident VTE in the community is from active cancer. The risk is higher in patients with cancers of the brain, pancreas, ovaries, colon, stomach, lungs, kidneys, or bones, and in patients with metastases.

• Genetic risk factors for VTE include factor V Leiden, prothrombin gene mutation G20210A, protein C and S deficiency, and anti-thrombin deficiency.

• VTE not only puts individuals at personal risk, but also at economic risk. A 2016 study determined that VTE (unprovoked) was associated with 52% greater risk of work-related disability.

• Health care costs related to VTE are estimated to be as high as $10 billion per year.