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Antithrombotic Therapy Practices in US Hospitals in an Era of Practice Guidelines
Victor F. Tapson, MD, FCCP;
Thomas M. Hyers, MD, FCCP;
Albert L. Waldo, MD;
David J. Ballard, MD;
Richard C. Becker, MD;
Joseph A. Caprini, MD, MS, FACS, RVT;
Roger Khetan, MD;
Ann K. Wittkowsky, PharmD, CACP;
Kevin J. Colgan, MA;
Alicia C. Shillington, PhD; for the NABOR (National Anticoagulation Benchmark and Outcomes Report) Steering Committee
Arch Intern Med. 2005;165:1458-1464.
Background Antithrombotic therapy is efficacious for the prevention of thromboembolic disease, but it necessitates careful risk-benefit assessment.
Methods Antithrombotic therapy data were retrospectively collected from inpatient medical records at 38 US hospitals. Patients treated for atrial fibrillation, acute myocardial infarction, deep vein thrombosis, or pulmonary embolism and patients given prophylaxis for total knee replacement, total hip replacement, or hip fracture surgery between July 1, 2000, and June 30, 2003, were randomly selected.
Results The medical records of 3778 patients (53.3% men) were included. The mean patient age was 66.1 years. Of patients with atrial fibrillation at high risk for stroke, only 54.7% received warfarin sodium, and 20.6% received neither aspirin nor warfarin. Of patients with acute myocardial infarction, only 75.5% received aspirin on hospital arrival. After orthopedic surgery procedures, only 85.6% of patients received prophylaxis with a parenteral anticoagulant agent or warfarin. In 49.4% of patients with deep vein thrombosis, pulmonary embolism, or both, unfractionated or low-molecular-weight heparin use was discontinued before an international normalized ratio of 2.0 or greater was achieved for 2 consecutive days. Patients with deep vein thrombosis or pulmonary embolism were rarely discharged from the hospital with bridge therapy (an injectable anticoagulant agent plus warfarin), although the length of hospitalization was significantly shorter than if discharged taking warfarin alone (4.0 vs 8.1 days; P < .001).
Conclusions A significant percentage of hospitalized patients do not receive adequate antithrombotic therapy for the primary and secondary prevention of thromboembolic disease.
Author Affiliations: Division of Pulmonary Medicine (Dr Tapson) and Duke Clinical Research Institute (Dr Becker), Duke University Medical Center, Durham, NC; C.A.R.E. Clinical Research, St Louis, Mo (Dr Hyers); Department of Cardiology, University Hospital of Cleveland, Cleveland, Ohio (Dr Waldo); Institute for Health Care Research and Improvement (Dr Ballard) and Health Texas Provider Network and Baylor University Medical Center (Dr Khetan), Baylor Health Care System, Dallas, Tex; Evanston Northwestern Healthcare and Feinberg School of Medicine, Evanston, Ill (Dr Caprini); Anticoagulation Services, University of Washington Medical Center, Seattle (Dr Wittkowsky); and EPI-Q Inc, Oakbrook Terrace, Ill (Mr Colgan and Dr Shillington).
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