Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey)

www.medscape.com

Abstract and Introduction

Abstract

Objective: To evaluate venous thromboembolism (VTE) risk in patients who underwent a major operation,

including the use of, and factors influencing, American College of Chest Physicians-recommended types of VTE

prophylaxis.

Summary background data: The Epidemiologic International Day for the Evaluation of Patients at Risk for

Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) survey, conducted in 358 hospitals

in 32 countries, reported that globally, more than 40% of at-risk patients do not receive VTE prophylaxis. Limited

data are available regarding VTE prophylaxis practices according to surgery type and patient characteristics.

Methods: Patients aged ≥18 years undergoing major surgery were included in this prespecified subanalysis.

VTE risk and use of prophylaxis were determined from hospital medical records according to the 2004 American

College of Chest Physicians guidelines. Multivariable analyses were performed to identify factors associated

with VTE prophylaxis use.

Results: Of the 18,461 patients in ENDORSE who had undergone major surgery, 17,084 (92.5%) were at-risk

for VTE and 10,638 (62.3%) received prophylaxis. Use of prophylaxis varied according to major surgery type

from 86.0% for orthopedic surgery to 53.8% in urologic/gynecologic and 53.6% in other procedures. Major

orthopedic surgery was most strongly associated with prophylaxis use (hip replacement: odds ratio 6.2, 95%

confidence interval [CI] 5.0–7.6; knee replacement: odds ratio 5.9, 95% CI 4.6–7.8).

Conclusions: The majority of surgical patients are at high-risk for VTE. Despite long-standing recognition of the

high-risk for VTE in surgical patients, thromboprophylaxis remains underutilized.

Introduction

Venous thromboembolism (VTE) remains an important clinical problem in surgical practice despite the benefits

of pharmacological thromboprophylaxis for the prevention of deep vein thrombosis (DVT) and fatal pulmonary

embolism (PE) having been established more than 30 years ago.[1–3] Furthermore, as many as one-third of

these thrombi could lead to PE, which is recognized as the most common preventable cause of inpatient

mortality.[4]

VTE prophylaxis reduces the relative risk of postoperative DVT by up to 75%, and reduces the relative risk for

nonfatal PE and fatal PE in surgical patients by 40% and 64%, respectively.[5] Prophylaxis also reduces all-

cause mortality in this patient population.[5]

Evidence-based guidelines from the American College of Chest Physicians (ACCP) categorize VTE risk and

recommend prophylaxis regimens according to type of operation and known patient risk factors.[6] General

surgery is associated with moderate risk for VTE; operations for cancer are associated with higher risk; and

major orthopedic surgery is considered to put patients at the highest risk with up to an 80% chance of

developing postoperative DVT.[6,7] Despite the solid body of evidence that validates both the risk for VTE and

benefits of thromboprophylaxis in surgical patients, the recent Epidemiologic International Day for the Evaluation

of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) survey

reported that only 59% of patients admitted to surgical wards and considered at-risk for VTE received

thromboprophylaxis.[6,8]

From Annals of Surgery

Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey): Findings in Surgical PatientsAjay K. Kakkar, MD, PhD; Alexander T. Cohen, MD; Victor F. Tapson, MD; Jean-Francois Bergmann, MD; Samuel Z. Goldhaber, MD; Bruno Deslandes; Wei Huang, MS; Frederick A. Anderson, Jr., PhD

Posted: 04/02/2010; Annals of Surgery. 2010;251(2):330-338. © 2010 Lippincott Williams & Wilkins

of 22Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (...

4/18/2010http://www.medscape.com/viewarticle/718702_print

In this analysis of the ENDORSE surgical population, we report VTE risk, rates of prophylaxis, and the influence

of site of operation, age, bleeding risk, and presence of malignancy on prophylaxis practices in patients who

underwent surgery in acute care hospitals. In addition, we evaluate the key factors associated with the decision

to provide VTE prophylaxis to this patient population.

Methods

Study Design

The ENDORSE survey was a cross-sectional, global survey of VTE risk and prophylaxis provision in the acute

care hospital setting. The study design has been published in detail elsewhere.[8] In this prespecified, surgical

population analysis, we evaluated VTE risk and use of recommended prophylaxis in patients who had

undergone a major surgical procedure by the day of survey according to the 2004 ACCP guidelines.[6]

Study Population

Eligible patients were enrolled between August 2006 and January 2007 from 358 participating hospitals across

32 countries in 6 continents.[8] Participating hospitals contained at least 50 acute care beds, routinely performed

major surgical procedures, and admitted patients for the treatment of acute medical illnesses. Ethics committee

approval for the survey was obtained according to national and local regulations.

Patients aged ≥18 years admitted to a surgical ward and undergoing elective or emergency major surgery,

defined as an operation which required general or epidural anesthesia and lasting ≥45 minutes, were eligible for

inclusion in this surgical population analysis.

Data Collection

Data including patient demographics, admission and postadmission diagnoses, surgery type, surgical indication,

VTE risk factors (as defined in the 2004 ACCP guidelines),[6] bleeding risk factors, duration of stay, and VTE

prophylaxis type were collected from a review of hospital charts by trained data abstractors.[8]

Assessment of VTE Risk and Prophylaxis

VTE risk and use of recommended prophylaxis were evaluated according to the 2004 ACCP guideline criteria

for surgical patients.[6]

Patients were considered to be at sufficient VTE risk to warrant prophylaxis if they: had multiple risk factors for

VTE at the time of surgery, underwent hip or knee arthroplasty, or were admitted for major trauma or spinal cord

injury; underwent surgery aged >60 years with no additional risk factors for VTE, or were aged 40 to 60 years

with risk factors; or underwent surgery and were aged 40 to 60 years or underwent minor surgery and had

additional risk factors for VTE.[6]

Recommended types of VTE prophylaxis included pharmacological agents (low molecular weight heparin,

unfractionated heparin, or vitamin K antagonists), mechanical prophylaxis (graduated compression stockings or

intermittent pneumatic compression), or a combination of both. Only the type of prophylaxis (not dose or

duration) was considered.

Analysis of Factors Influencing VTE Risk and Prophylaxis Use

Surgical procedures were grouped into the following categories: major orthopedic (hip replacement, knee

replacement, hip fracture repair), abdominal/thoracic (colon/small bowel, rectosigmoid, gastric, hepatobiliary,

thoracic), vascular, urologic/gynecologic, and other (curative arthroscopy, other orthopedic trauma, and other

surgeries).

Patient medical histories were used to determine the number of VTE risk factors present before and during

hospitalization. Defined risk factors (in addition to surgical procedure performed) include: previous VTE,

admission with major trauma, significant medical comorbidity, and immobilization.[6]



Use of Prophylaxis According to Bleeding Risk and the Presence of Active Malignancy

Patients were considered to have a high bleeding risk, sufficient to be a contraindication to pharmacological

prophylaxis, if they presented with or developed: intracranial hemorrhage, hepatic impairment, bleeding at

hospital admission, active gastroduodenal ulcer, or a known bleeding disorder.[9] Moderate bleeding risk was

defined as patients who did not have high bleeding risk who had any of the following at current admission:

significant renal impairment, low platelet count (<100,000/µL), use of aspirin or NSAID (continued during current

admission). Patients who presented none of the above at current admission were considered at low risk for

bleeding.

Use of VTE prophylaxis in patients with cancer was assessed in those who underwent abdominal or

urologic/gynecologic surgery. Patients were subdivided according to surgical indication: for the cancer itself

(surgery for cancer), unrelated to the cancer (surgery with cancer), or without a cancer diagnosis (no/unknown

cancer).

Statistical Analysis

Quantitative data were summarized as median values with interquartile range. Categorical data were

summarized as the number and proportion of the population. Summary data are reported globally, by country,

and by type of surgical procedure. For the main outcomes, 95% confidence intervals (CI) were calculated.

Two multivariable logistic regression analyses were performed to assess the key factors associated with the use

of recommended types of prophylaxis. The first analysis included the following candidate variables: baseline

characteristics, type of surgery, VTE risk factors, and bleeding risk factors. To further investigate the potential

role of nonsurgery type-related risk factors in the association between prophylaxis use and comorbidities a

second multivariable analysis was performed, using the above candidate variables, excluding surgery type.

Criteria for entry and removal of candidate variables in the stepwise analysis were assigned a significance level

of P < 0.05. Adjusted odds ratios and 95% CI were reported.

SAS version 9.1 was used for all statistical analyses.

Results

Of the total 68,183 evaluable patients enrolled in the ENDORSE study, 30,827 (45.2%) were classified as

evaluable surgical patients (Fig. 1).[8] On the day of the survey, 18,461 evaluable surgical patients had

undergone major surgery. Of these, 17,084 (92.5%) were considered at risk for VTE and of these 10,638

(62.3%) received ACCP-recommended types of VTE prophylaxis.



Figure 1. Study population included in the ENDORSE survey.*VTE risk defined according to 2004 ACCP

guidelines.6

Patient Baseline Characteristics

Baseline characteristics of patients who underwent surgery and were at-risk of VTE are shown in Table 1. The

most common preadmission risk factors for VTE were obesity, chronic heart failure, and chronic pulmonary

disease. After hospital admission, the most common VTE risk factors, in addition to major operation, were

complete immobilization, reduced mobility (with bathroom privileges), and admission to an intensive care unit

(Table 1).

Table 1. Baseline Characteristics of Patients Who Have Undergone Surgery and Are At-Risk

for VTE

Total

n (%)

Surgery Type, n (%)

Major

Orthopedic Abdominal/Thoracic Urologic/Gynecologic Vascular Other



Patient

Characteristics*

N =

17,084 n = 2300 n = 4527 n = 2344 n = 1012

n =

6901

No. females, (%)8120

(48.3)

1,456

(64.4)2069 (46.5) 1236 (53.6)

407

(41.0)

2952

(43.4)

Median age,

years (range)

61.0

(48.0–

73.0)

72.0 (62.0–

80.0)62.0 (50.0–73.0) 60.0 (47.0–71.0)

66.0

(55.5–

74.0)

55.0

(43.0

–

69.0)

Median length of

hospitalization up

to survey date,

days (range)

7.0

(3.0–

14.0)

6.0 (3.0–

12.0)7.0 (3.0–15.0) 5.0 (2.0–9.0)

8.0 (3.0–

16.0)

7.0

(3.0–

14.0)

Median body

mass index, kg/m2

(range)

26.3

(23.4–

30.3)

27.7 (24.5–

31.7)25.8 (23.0–29.9) 26.0 (23.5–29.4)

26.4

(23.6–

29.5)

26.1

(23.1

–

30.0)

Preadmission

risk factors for

VTE*, n (%)

N =

16,143 n = 2202 n = 4345 n = 2231 n = 994

n =

6371

Previous VTE425

(2.6)77 (3.5) 130 (3.0) 45 (2.0) 32 (3.2)

141

(2.2)

Thrombophilia41

(0.3)5 (0.2) 8 (0.2) 7 (0.3) 2 (0.2)

19

(0.3)

Varicose veins or

venous

insufficiency

1213

(7.5)199 (9.0) 265 (6.1) 173 (7.8)

195

(19.6)

381

(6.0)

Postmenopausal

hormone

replacement

therapy

134

(0.8)25 (1.1) 31 (0.7) 34 (1.5) 3 (0.3)

41

(0.6)

Chronic

pulmonary disease

1387

(8.6)210 (9.5) 449 (10.3) 157 (7.0)

116

(11.7)

455

(7.1)

Long-term

immobility

386

(2.4)58 (2.6) 73 (1.7) 26 (1.2) 35 (3.5)

194

(3.0)

Pregnancy

(within 3 months)

56

(0.3)0 8 (0.2) 33 (1.5) 1 (0.1)

14

(0.2)

Obesity1758

(10.9)326 (14.8) 486 (11.2) 225 (10.1)

121

(12.2)

600

(9.4)

Contraceptives151

(0.9)2 (0.1) 37 (0.9) 63 (2.8) 6 (0.6)

43

(0.7)

Chronic heart

failure

1390

(8.6)210 (9.5) 339 (7.8) 155 (6.9)

191

(19.2)

495

(7.8)

VTE risk during

hospitalization

N =

17,084 n = 2300 n = 4527 n = 2344 n = 1012

n =

6901



Admitted to

critical care unit

4207

(24.6)286 (12.4) 1635 (36.1) 318 (13.6)

383

(37.8)

1585

(23.0)

Central venous

catheter

2909

(17.0)158 (6.9) 1229 (27.1) 191 (8.1)

308

(30.4)

1023

(14.8)

Mechanical

ventilation

2244

(13.1)121 (5.3) 916 (20.2) 126 (5.4)

227

(22.4)

854

(12.4)

Immobile with

bathroom

privileges

4056

(23.7)565 (24.6) 1066 (23.5) 533 (22.7)

207

(20.5)

1685

(24.4)

Complete

immobilization

6646

(38.9)

1162

(50.5)1755 (38.8) 704 (30.0)

427

(42.2)

2598

(37.6)

Surgery for

cancer

2631

(15.4)10 (0.4) 1253 (27.7) 676 (28.8) 4 (0.4)

688

(10.0)

Cancer (active)212

(1.2)24 (1.0) 66 (1.5) 45 (1.9) 9 (0.9)

68

(1.0)

No/unknown

cancer

14,241

(83.4)

2266

(98.5)3208 (70.9) 1623 (69.2)

999

(98.7)

6145

(89.0)

*Data on some patient characteristics and prehospital admission risk factors for VTE were

unavailable for some surgical patients.

Table 1. Baseline Characteristics of Patients Who Have Undergone Surgery and Are At-Risk

for VTE

Total

n (%)

Surgery Type, n (%)

Major

Orthopedic Abdominal/Thoracic Urologic/Gynecologic Vascular Other

Patient

Characteristics*

N =

17,084 n = 2300 n = 4527 n = 2344 n = 1012

n =

6901

No. females, (%)8120

(48.3)

1,456

(64.4)2069 (46.5) 1236 (53.6)

407

(41.0)

2952

(43.4)

Median age,

years (range)

61.0

(48.0–

73.0)

72.0 (62.0–

80.0)62.0 (50.0–73.0) 60.0 (47.0–71.0)

66.0

(55.5–

74.0)

55.0

(43.0

–

69.0)

Median length of

hospitalization up

to survey date,

days (range)

7.0

(3.0–

14.0)

6.0 (3.0–

12.0)7.0 (3.0–15.0) 5.0 (2.0–9.0)

8.0 (3.0–

16.0)

7.0

(3.0–

14.0)

Median body

mass index, kg/m2

(range)

26.3

(23.4–

30.3)

27.7 (24.5–

31.7)25.8 (23.0–29.9) 26.0 (23.5–29.4)

26.4

(23.6–

29.5)

26.1

(23.1

–

30.0)

Preadmission

risk factors for

VTE*, n (%)

N =

16,143 n = 2202 n = 4345 n = 2231 n = 994

n =

6371



Previous VTE425

(2.6)77 (3.5) 130 (3.0) 45 (2.0) 32 (3.2)

141

(2.2)

Thrombophilia41

(0.3)5 (0.2) 8 (0.2) 7 (0.3) 2 (0.2)

19

(0.3)

Varicose veins or

venous

insufficiency

1213

(7.5)199 (9.0) 265 (6.1) 173 (7.8)

195

(19.6)

381

(6.0)

Postmenopausal

hormone

replacement

therapy

134

(0.8)25 (1.1) 31 (0.7) 34 (1.5) 3 (0.3)

41

(0.6)

Chronic

pulmonary disease

1387

(8.6)210 (9.5) 449 (10.3) 157 (7.0)

116

(11.7)

455

(7.1)

Long-term

immobility

386

(2.4)58 (2.6) 73 (1.7) 26 (1.2) 35 (3.5)

194

(3.0)

Pregnancy

(within 3 months)

56

(0.3)0 8 (0.2) 33 (1.5) 1 (0.1)

14

(0.2)

Obesity1758

(10.9)326 (14.8) 486 (11.2) 225 (10.1)

121

(12.2)

600

(9.4)

Contraceptives151

(0.9)2 (0.1) 37 (0.9) 63 (2.8) 6 (0.6)

43

(0.7)

Chronic heart

failure

1390

(8.6)210 (9.5) 339 (7.8) 155 (6.9)

191

(19.2)

495

(7.8)

VTE risk during

hospitalization

N =

17,084 n = 2300 n = 4527 n = 2344 n = 1012

n =

6901

Admitted to

critical care unit

4207

(24.6)286 (12.4) 1635 (36.1) 318 (13.6)

383

(37.8)

1585

(23.0)

Central venous

catheter

2909

(17.0)158 (6.9) 1229 (27.1) 191 (8.1)

308

(30.4)

1023

(14.8)

Mechanical

ventilation

2244

(13.1)121 (5.3) 916 (20.2) 126 (5.4)

227

(22.4)

854

(12.4)

Immobile with

bathroom

privileges

4056

(23.7)565 (24.6) 1066 (23.5) 533 (22.7)

207

(20.5)

1685

(24.4)

Complete

immobilization

6646

(38.9)

1162

(50.5)1755 (38.8) 704 (30.0)

427

(42.2)

2598

(37.6)

Surgery for

cancer

2631

(15.4)10 (0.4) 1253 (27.7) 676 (28.8) 4 (0.4)

688

(10.0)

Cancer (active)212

(1.2)24 (1.0) 66 (1.5) 45 (1.9) 9 (0.9)

68

(1.0)

No/unknown

cancer

14,241

(83.4)

2266

(98.5)3208 (70.9) 1623 (69.2)

999

(98.7)

6145

(89.0)



The frequency of contraindications to pharmacological prophylaxis in surgical patients is shown in Table 2.[9]

Overall, 9.2% of surgical patients at-risk of VTE presented with potential contraindications to anticoagulation.

The most common contraindication was bleeding at the time of hospital admission.

VTE Risk and Prophylaxis According to Surgery Type

The proportion of patients at risk for VTE who received recommended prophylaxis ranged from 86.0% in

patients undergoing major orthopedic surgery to 53.8% in urologic/gynecologic and 53.6% in other procedures

(Table 3).

*Data on some patient characteristics and prehospital admission risk factors for VTE were

unavailable for some surgical patients.

Table 2. Contraindications to Anticoagulation in Patients Who Have Undergone Surgery and

Are at Risk for Venous Thromboembolism

Total, n

(%)(N =

17,084)

Surgery Type, n (%)

Major

Orthopedic

(n = 2300)

Abdominal/Thoracic

(n = 4527)

Urologic/Gynecologic

(n = 2344)

Vascular

(n =

1012)

Other

(n =

6901)

Contraindications to anticoagulant prophylaxis*

Intracranial

hemorrhage

312

(1.8)6 (0.3) 12 (0.3) 0 20 (2.0)

274

(4.0)

Known

bleeding

disorder

(congenital or

acquired)

77 (0.5) 8 (0.3) 27 (0.6) 7 (0.3) 2 (0.2)33

(0.5)

Clinically

relevant hepatic

impairment

305

(1.8)18 (0.8) 192 (4.2) 15 (0.6) 8 (0.8)

72

(1.0)

Bleeding at

hospital

admission

836

(4.9)51 (2.2) 230 (5.1) 165 (7.0) 44 (4.3)

346

(5.0)

Active

gastroduodenal

Ulcer

206

(1.2)14 (0.6) 150 (3.3) 6 (0.3) 8 (0.8)

28

(0.4)

Additional bleeding risk factors

Significant

renal

impairment

811

(4.7)63 (2.7) 188 (4.2) 194 (8.3)

104

(10.3)

262

(3.8)

Low platelet

count

(<100,000/µL)

259

(1.5)28 (1.2) 91 (2.0) 17 (0.7) 21 (2.1)

102

(1.5)

*Defined in accordance with reference 9.



Table 3. VTE Risk and Prophylaxis According to Type of Surgery and by Country

Country

Surgery Types, n (%)

Major Orthopedic Abdominal/Thoracic Urologic/Gynecologic Vascular Other

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-Risk

for VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

Receiving

Algeria (n =

252)

23

(100.0)

23

(100.0)

55

(93.2)31 (56.4)

39

(90.7)33 (84.6)

2

(100)1 (50)

110

(88)73

Australia (n

= 371)

73

(100.0)69 (94.5)

86

(98.9)72 (83.7)

33

(97.1)19 (57.6)

16

(100)9 (56.3)

157

(97.5)

Bangladesh

(n = 491)

4

(100.0)0

114

(58.2)0

77

(57.0)0

2

(100)0

131

(85.1)

Brazil (n =

417)

19

(100.0)13 (68.4)

100

(93.5)53 (53.0)

62

(84.9)16 (25.8)

54

(98.2)30 (55.6)

149

(91.4)

Bulgaria (n

= 867)

113

(100.0)

109

(96.5)

215

(92.3)164 (76.3)

140

(90.9)77 (55.0)

26

(100)21 (80.8)

318

(93.3)

Colombia

(n = 151)

12

(100.0)6 (50.0)

41

(85.4)17 (41.5)

34

(94.4)10 (29.4)

10

(90.9)9 (90)

42

(95.5)16 (38.1)

Czech

Republic (n

= 548)

110

(100.0)

101

(91.8)

105

(92.9)81 (77.1)

90

(95.7)67 (74.4)

22

(95.7)14 (63.6)

194

(93.3)

Egypt (n =

266)

8

(100.0)6 (75.0)

68

(81.9)24 (35.3)

29

(70.7)10 (34.5)

11

(91.7)6 (54.5)

102

(83.6)31 (30.4)

France (n =

614)

85

(100.0)73 (85.9)

196

(94.7)156 (79.6)

49

(94.2)32 (65.3)

21

(100)9 (42.9)

235

(94.4)

Germany (n

= 826)

206

(100.0)

198

(96.1)

134

(92.4)129 (96.3)

105

(91.3)105 (100.0)

87

(98.9)67 (77.0)

254

(93.4)

Greece (n

= 478)

78

(100.0)77 (98.7)

114

(92.7)86 (75.4)

83

(95.4)49 (59.0)

34

(94.4)23 (67.6)

135

(87.7)97 (71.9)

Hungary (n

= 249)

28

(100.0)

28

(100.0)

77

(85.6)74 (96.1)

29

(96.7)25 (86.2)

31

(100)31 (100)

67

(95.7)49 (73.1)

India (n =

584)

30

(100.0)8 (26.7)

117

(84.8)39 (33.3)

76

(84.4)5 (6.6)

29

(93.5)14 (48.3)

274

(92.9)38 (13.9)

Ireland (n =

163)

22

(100.0)18 (81.8)

38

(84.4)34 (89.5)

15

(93.8)10 (66.7)

12

(100)4 (33.3)

65

(95.6)34 (52.3)

Kuwait (n =

76)NA NA

22

(62.9)13 (59.1) 1 (50.0) 0 3 (75) 1 (33.3)

28

(80)15

Mexico (n =

312)

11

(100.0)9 (81.8)

84

(78.5)36 (42.9)

38

(82.6)10 (26.3)

17

(100)13 (76.5)

121

(92.4)54 (44.6)

Pakistan (n

= 342)

3

(100.0)1 (33.3)

70

(67.3)8 (11.4)

57

(58.2)3 (5.3) 6 (75) 2 (33.3)

116

(89.9)14



Of the patients admitted for emergency surgery (n = 4269) and elective surgery (n = 14,192), 3854 (90.3%) and

13,230 (93.2%) were at risk for VTE, respectively. However, only 57.9% of emergency and 66.3% of elective

surgery patients received any prophylaxis.

Poland (n =

550)

74

(100.0)72 (97.3)

135

(93.1)96 (71.1)

77

(93.9)30 (39.0)

55

(96.5)43 (78.2)

164

(85.4)

Portugal (n

= 465)

57

(100.0)48 (84.2)

114

(92.7)82 (71.9)

73

(92.4)35 (47.9)

11

(100)6 (54.5)

187

(95.9)

Romania (n

= 1489)

124

(100.0)

117

(94.4)

385

(95.3)257 (66.8)

248

(95.8)176 (71.0)

43

(93.5)25 (58.1)

622

(94.8)

Russia (n =

1277)

61

(100.0)39 (63.9)

249

(85.3)93 (37.3)

155

(83.3)47 (30.3)

69

(94.5)49 (71)

591

(88.9)

Saudi

Arabia (n =

146)

13

(100.0)5 (38.5)

16

(53.3)7 (43.8) 7 (87.5) 3 (42.9)

3

(100)1 (33.3)

76

(82.6)28 (36.8)

Slovakia (n

= 548)

81

(100.0)78 (96.3)

111

(88.8)98 (88.3)

114

(93.4)70 (61.4)

23

(100)16 (69.6)

179

(90.9)

Spain (n =

657)

137

(100.0)

136

(99.3)

170

(98.8)148 (87.1)

108

(99.1)77 (71.3)

35

(97.2)23 (65.7)

193

(95.1)

Switzerland

(n = 752)

94

(100.0)84 (89.4)

207

(94.1)173 (83.6)

71

(95.9)64 (90.1)

41

(95.3)29 (70.7)

294

(91.6)238 (81)

Thailand (n

= 543)

27

(100.0)0

132

(95.7)1 (0.8)

68

(86.1)0

15

(100)0

275

(96.8)

Tunisia (n =

103)NA NA

51

(87.9)46 (90.2)

10

(83.3)9 (90.0)

5

(100)0

23

(82.1)15 (65.2)

Turkey (n =

299)

40

(100.0)24 (60.0)

85

(95.5)37 (43.5)

30

(90.9)4 (13.3) 8 (80) 5 (62.5)

124

(97.6)

United Arab

Emirates (n

= 125)

13

(100.0)8 (61.5)

16

(59.3)6 (37.5)

11

(64.7)5 (45.5) NA NA

64

(94.1)29

United

Kingdom (n

= 1272)

281

(100.0)

218

(77.6)

340

(92.9)290 (85.3)

143

(94.7)105 (73.4)

66

(100)52 (78.8)

385

(94.4)

United

States (n =

3044)

471

(100.0)

409

(86.8)

825

(95.8)668 (81.0)

248

(91.9)164 (66.1)

250

(100)

171

(68.4)

1135

(95.2)

Venezuela

(n = 184)

2

(100.0)2 (100.0)

55

(94.8)4 (7.3)

24

(92.3)1 (4.2)

5

(100)2 (40)

91

(97.8)19 (20.9)

Total (N =

18,461)

2300

(100.0)

1979

(86.0)

4527

(90.0)3023 (66.8)

2344

(88.4)1261 (53.8)

1012

(97.5)

676

(66.8)

6901

(92.7)

NA indicates not applicable; Px, prophylaxis; VTE, venous thromboembolism.

of 22Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Settin...


Country-specific Use of VTE Prophylaxis

Globally, the proportion of major surgery patients at-risk for VTE varied from 66.8% to 98.4% between

participating countries (Fig. 2A, Table 3). Use of recommended prophylaxis also varied (between-country range

0.3%–93.9%; Fig. 2B, Table 3).


Country



At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-Risk

for VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

Receiving

Algeria (n =

252)

23

(100.0)

23

(100.0)

55

(93.2)31 (56.4)

39

(90.7)33 (84.6)

2

(100)1 (50)

110

(88)73

Australia (n

= 371)

73

(100.0)69 (94.5)

86

(98.9)72 (83.7)

33

(97.1)19 (57.6)

16

(100)9 (56.3)

157

(97.5)

Bangladesh

(n = 491)

4

(100.0)0

114

(58.2)0

77

(57.0)0

2

(100)0

131

(85.1)

Brazil (n =

417)

19

(100.0)13 (68.4)

100

(93.5)53 (53.0)

62

(84.9)16 (25.8)

54

(98.2)30 (55.6)

149

(91.4)

Bulgaria (n

= 867)

113

(100.0)

109

(96.5)

215

(92.3)164 (76.3)

140

(90.9)77 (55.0)

26

(100)21 (80.8)

318

(93.3)

Colombia

(n = 151)

12

(100.0)6 (50.0)

41

(85.4)17 (41.5)

34

(94.4)10 (29.4)

10

(90.9)9 (90)

42

(95.5)16 (38.1)

Czech

Republic (n

= 548)

110

(100.0)

101

(91.8)

105

(92.9)81 (77.1)

90

(95.7)67 (74.4)

22

(95.7)14 (63.6)

194

(93.3)

Egypt (n =

266)

8

(100.0)6 (75.0)

68

(81.9)24 (35.3)

29

(70.7)10 (34.5)

11

(91.7)6 (54.5)

102

(83.6)31 (30.4)

France (n =

614)

85

(100.0)73 (85.9)

196

(94.7)156 (79.6)

49

(94.2)32 (65.3)

21

(100)9 (42.9)

235

(94.4)

Germany (n

= 826)

206

(100.0)

198

(96.1)

134

(92.4)129 (96.3)

105

(91.3)105 (100.0)

87

(98.9)67 (77.0)

254

(93.4)

Greece (n

= 478)

78

(100.0)77 (98.7)

114

(92.7)86 (75.4)

83

(95.4)49 (59.0)

34

(94.4)23 (67.6)

135

(87.7)97 (71.9)

Hungary (n

= 249)

28

(100.0)

28

(100.0)

77

(85.6)74 (96.1)

29

(96.7)25 (86.2)

31

(100)31 (100)

67

(95.7)49 (73.1)

India (n =

584)

30

(100.0)8 (26.7)

117

(84.8)39 (33.3)

76

(84.4)5 (6.6)

29

(93.5)14 (48.3)

274

(92.9)38 (13.9)

Ireland (n =

163)

22

(100.0)18 (81.8)

38

(84.4)34 (89.5)

15

(93.8)10 (66.7)

12

(100)4 (33.3)

65

(95.6)34 (52.3)

Kuwait (n =

76)NA NA

22

(62.9)13 (59.1) 1 (50.0) 0 3 (75) 1 (33.3)

28

(80)15



Mexico (n =

312)

11

(100.0)9 (81.8)

84

(78.5)36 (42.9)

38

(82.6)10 (26.3)

17

(100)13 (76.5)

121

(92.4)54 (44.6)

Pakistan (n

= 342)

3

(100.0)1 (33.3)

70

(67.3)8 (11.4)

57

(58.2)3 (5.3) 6 (75) 2 (33.3)

116

(89.9)14

Poland (n =

550)

74

(100.0)72 (97.3)

135

(93.1)96 (71.1)

77

(93.9)30 (39.0)

55

(96.5)43 (78.2)

164

(85.4)

Portugal (n

= 465)

57

(100.0)48 (84.2)

114

(92.7)82 (71.9)

73

(92.4)35 (47.9)

11

(100)6 (54.5)

187

(95.9)

Romania (n

= 1489)

124

(100.0)

117

(94.4)

385

(95.3)257 (66.8)

248

(95.8)176 (71.0)

43

(93.5)25 (58.1)

622

(94.8)

Russia (n =

1277)

61

(100.0)39 (63.9)

249

(85.3)93 (37.3)

155

(83.3)47 (30.3)

69

(94.5)49 (71)

591

(88.9)

Saudi

Arabia (n =

146)

13

(100.0)5 (38.5)

16

(53.3)7 (43.8) 7 (87.5) 3 (42.9)

3

(100)1 (33.3)

76

(82.6)28 (36.8)

Slovakia (n

= 548)

81

(100.0)78 (96.3)

111

(88.8)98 (88.3)

114

(93.4)70 (61.4)

23

(100)16 (69.6)

179

(90.9)

Spain (n =

657)

137

(100.0)

136

(99.3)

170

(98.8)148 (87.1)

108

(99.1)77 (71.3)

35

(97.2)23 (65.7)

193

(95.1)

Switzerland

(n = 752)

94

(100.0)84 (89.4)

207

(94.1)173 (83.6)

71

(95.9)64 (90.1)

41

(95.3)29 (70.7)

294

(91.6)238 (81)

Thailand (n

= 543)

27

(100.0)0

132

(95.7)1 (0.8)

68

(86.1)0

15

(100)0

275

(96.8)

Tunisia (n =

103)NA NA

51

(87.9)46 (90.2)

10

(83.3)9 (90.0)

5

(100)0

23

(82.1)15 (65.2)

Turkey (n =

299)

40

(100.0)24 (60.0)

85

(95.5)37 (43.5)

30

(90.9)4 (13.3) 8 (80) 5 (62.5)

124

(97.6)

United Arab

Emirates (n

= 125)

13

(100.0)8 (61.5)

16

(59.3)6 (37.5)

11

(64.7)5 (45.5) NA NA

64

(94.1)29

United

Kingdom (n

= 1272)

281

(100.0)

218

(77.6)

340

(92.9)290 (85.3)

143

(94.7)105 (73.4)

66

(100)52 (78.8)

385

(94.4)

United

States (n =

3044)

471

(100.0)

409

(86.8)

825

(95.8)668 (81.0)

248

(91.9)164 (66.1)

250

(100)

171

(68.4)

1135

(95.2)

Venezuela

(n = 184)

2

(100.0)2 (100.0)

55

(94.8)4 (7.3)

24

(92.3)1 (4.2)

5

(100)2 (40)

91

(97.8)19 (20.9)

Total (N =

18,461)

2300

(100.0)

1979

(86.0)

4527

(90.0)3023 (66.8)

2344

(88.4)1261 (53.8)

1012

(97.5)

676

(66.8)

6901

(92.7)





Country



At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-Risk

for VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

At-Risk

Receiving

Px

At-

Risk

for

VTE

Receiving

Algeria (n =

252)

23

(100.0)

23

(100.0)

55

(93.2)31 (56.4)

39

(90.7)33 (84.6)

2

(100)1 (50)

110

(88)73

Australia (n

= 371)

73

(100.0)69 (94.5)

86

(98.9)72 (83.7)

33

(97.1)19 (57.6)

16

(100)9 (56.3)

157

(97.5)

Bangladesh

(n = 491)

4

(100.0)0

114

(58.2)0

77

(57.0)0

2

(100)0

131

(85.1)

Brazil (n =

417)

19

(100.0)13 (68.4)

100

(93.5)53 (53.0)

62

(84.9)16 (25.8)

54

(98.2)30 (55.6)

149

(91.4)

Bulgaria (n

= 867)

113

(100.0)

109

(96.5)

215

(92.3)164 (76.3)

140

(90.9)77 (55.0)

26

(100)21 (80.8)

318

(93.3)

Colombia

(n = 151)

12

(100.0)6 (50.0)

41

(85.4)17 (41.5)

34

(94.4)10 (29.4)

10

(90.9)9 (90)

42

(95.5)16 (38.1)

Czech

Republic (n

= 548)

110

(100.0)

101

(91.8)

105

(92.9)81 (77.1)

90

(95.7)67 (74.4)

22

(95.7)14 (63.6)

194

(93.3)

Egypt (n =

266)

8

(100.0)6 (75.0)

68

(81.9)24 (35.3)

29

(70.7)10 (34.5)

11

(91.7)6 (54.5)

102

(83.6)31 (30.4)

France (n =

614)

85

(100.0)73 (85.9)

196

(94.7)156 (79.6)

49

(94.2)32 (65.3)

21

(100)9 (42.9)

235

(94.4)

Germany (n

= 826)

206

(100.0)

198

(96.1)

134

(92.4)129 (96.3)

105

(91.3)105 (100.0)

87

(98.9)67 (77.0)

254

(93.4)

Greece (n

= 478)

78

(100.0)77 (98.7)

114

(92.7)86 (75.4)

83

(95.4)49 (59.0)

34

(94.4)23 (67.6)

135

(87.7)97 (71.9)

Hungary (n

= 249)

28

(100.0)

28

(100.0)

77

(85.6)74 (96.1)

29

(96.7)25 (86.2)

31

(100)31 (100)

67

(95.7)49 (73.1)

India (n =

584)

30

(100.0)8 (26.7)

117

(84.8)39 (33.3)

76

(84.4)5 (6.6)

29

(93.5)14 (48.3)

274

(92.9)38 (13.9)

Ireland (n =

163)

22

(100.0)18 (81.8)

38

(84.4)34 (89.5)

15

(93.8)10 (66.7)

12

(100)4 (33.3)

65

(95.6)34 (52.3)

Kuwait (n =

76)NA NA

22

(62.9)13 (59.1) 1 (50.0) 0 3 (75) 1 (33.3)

28

(80)15

Mexico (n =

312)

11

(100.0)9 (81.8)

84

(78.5)36 (42.9)

38

(82.6)10 (26.3)

17

(100)13 (76.5)

121

(92.4)54 (44.6)

Pakistan (n

= 342)

3

(100.0)1 (33.3)

70

(67.3)8 (11.4)

57

(58.2)3 (5.3) 6 (75) 2 (33.3)

116

(89.9)14



Poland (n =

550)

74

(100.0)72 (97.3)

135

(93.1)96 (71.1)

77

(93.9)30 (39.0)

55

(96.5)43 (78.2)

164

(85.4)

Portugal (n

= 465)

57

(100.0)48 (84.2)

114

(92.7)82 (71.9)

73

(92.4)35 (47.9)

11

(100)6 (54.5)

187

(95.9)

Romania (n

= 1489)

124

(100.0)

117

(94.4)

385

(95.3)257 (66.8)

248

(95.8)176 (71.0)

43

(93.5)25 (58.1)

622

(94.8)

Russia (n =

1277)

61

(100.0)39 (63.9)

249

(85.3)93 (37.3)

155

(83.3)47 (30.3)

69

(94.5)49 (71)

591

(88.9)

Saudi

Arabia (n =

146)

13

(100.0)5 (38.5)

16

(53.3)7 (43.8) 7 (87.5) 3 (42.9)

3

(100)1 (33.3)

76

(82.6)28 (36.8)

Slovakia (n

= 548)

81

(100.0)78 (96.3)

111

(88.8)98 (88.3)

114

(93.4)70 (61.4)

23

(100)16 (69.6)

179

(90.9)

Spain (n =

657)

137

(100.0)

136

(99.3)

170

(98.8)148 (87.1)

108

(99.1)77 (71.3)

35

(97.2)23 (65.7)

193

(95.1)

Switzerland

(n = 752)

94

(100.0)84 (89.4)

207

(94.1)173 (83.6)

71

(95.9)64 (90.1)

41

(95.3)29 (70.7)

294

(91.6)238 (81)

Thailand (n

= 543)

27

(100.0)0

132

(95.7)1 (0.8)

68

(86.1)0

15

(100)0

275

(96.8)

Tunisia (n =

103)NA NA

51

(87.9)46 (90.2)

10

(83.3)9 (90.0)

5

(100)0

23

(82.1)15 (65.2)

Turkey (n =

299)

40

(100.0)24 (60.0)

85

(95.5)37 (43.5)

30

(90.9)4 (13.3) 8 (80) 5 (62.5)

124

(97.6)

United Arab

Emirates (n

= 125)

13

(100.0)8 (61.5)

16

(59.3)6 (37.5)

11

(64.7)5 (45.5) NA NA

64

(94.1)29

United

Kingdom (n

= 1272)

281

(100.0)

218

(77.6)

340

(92.9)290 (85.3)

143

(94.7)105 (73.4)

66

(100)52 (78.8)

385

(94.4)

United

States (n =

3044)

471

(100.0)

409

(86.8)

825

(95.8)668 (81.0)

248

(91.9)164 (66.1)

250

(100)

171

(68.4)

1135

(95.2)

Venezuela

(n = 184)

2

(100.0)2 (100.0)

55

(94.8)4 (7.3)

24

(92.3)1 (4.2)

5

(100)2 (40)

91

(97.8)19 (20.9)

Total (N =

18,461)

2300

(100.0)

1979

(86.0)

4527

(90.0)3023 (66.8)

2344

(88.4)1261 (53.8)

1012

(97.5)

676

(66.8)

6901

(92.7)




Figure 2. Proportion of patients in participating countries who have undergone surgery and who are (A) at

-risk for VTE and (B) at-risk for VTE and receiving ACCP-recommended prophylaxis. ACCP indicates

American College of Chest Physicians; VTE, venous thromboembolism.

Additional Factors Influencing VTE Risk and Prophylaxis Use

Overall, 61% and 60% of major surgery patients aged 18 to 29 and 30 to 39 years, respectively, were

considered at-risk for VTE. All patients aged ≥40 years who underwent a major surgical procedure were

considered at-risk for VTE. The proportion of patients with high bleeding risk (sufficient to present a

contraindication to anticoagulant use) decreased with age, from 11% in patients aged 18 to 29 years to 6% of

patients aged ≥90 years.



Use of recommended prophylaxis in patients with 1 to 3 VTE risk factors was 58.0% (5911/10,188), compared

with 68.6% (4727/6896) in major surgery patients with >3 risk factors.

Use of Recommended Types of VTE Prophylaxis in Special Populations

Our data suggest that use of pharmacological agents alone was the most frequently used form of VTE

prophylaxis across all the patient subgroups assessed (Figs. 3A, B).



Figure 3. Types of VTE prophylaxis used according to (A) bleeding risk levels and the number of VTE risk

factors present and (B) an active malignancy diagnosis in patients undergoing abdominal, urologic or

gynecologic surgery. VTE risk factors in addition to surgery type were defined according to the 2004 ACCP

guidelines.6 VTE indicates venous thromboembolism.

The relative proportions of patients receiving pharmacological-only, mechanical-only, or combined

pharmacological and mechanical prophylaxis appears to vary according to both the number of risk factors for

VTE (1–3 vs >3 risk factors) and bleeding risk (low/moderate vs high) (Fig. 3A). Due to reduced use of

combined pharmacological and mechanical prophylaxis in patients with a high bleeding risk, we observed a

smaller difference in rates of use for mechanical alone versus combined pharmacological and mechanical

prophylaxis in these patients, compared with those with a low/moderate bleeding risk (Fig. 3A).

All patients with cancer who underwent abdominal, urologic, or gynecologic surgery were considered at-risk for

VTE (Table 4), as almost a third of these procedures were related to a cancer diagnosis. Patients undergoing

surgery for cancer more commonly received recommended prophylaxis, compared with those undergoing

surgical procedures unrelated to cancer (Table 4). A greater proportion of patients with cancer who underwent

surgical procedures unrelated to their cancer had a high bleeding risk compared with other subgroups (Table 4).

In addition, we observed a trend toward lower rates of pharmacological prophylaxis use in these patients (Fig.

3B). Use of pharmacological-only, mechanical-only, or a combination of the 2 appeared to be similar in

noncancer patients and in patients who underwent surgery for cancer.

Table 4. Risk for VTE and Bleeding in Patients Who Have Undergone Abdominal, Urologic, or

Gynecologic Surgery According to the Presence of an Active Malignancy Diagnosis

Active

Malignancy

Status*

At Risk for

VTE, n (%)

At Risk and Receiving ACCP-

Recommended Prophylaxis, n (%)

Bleeding Risk in At Risk

Patients, n (%)

High Moderate Low

Cancer

diagnosis 1868 (30.3) 1350 (72.3)

200

(10.7)291 (15.6)

1377

(73.7)

Surgery for

cancer1767 1295 (73.3)

183

(10.4)267 (15.1)

1317

(74.5)

Surgery with

cancer101 55 (54.5)

17

(16.8)24 (23.8) 60 (59.4)

No cancer

diagnosis 4304 (69.7) 2495 (58.0)

470

(10.9)837 (19.4)

2997

(69.6)

*Active malignancy status defined according to whether a patient had a cancer diagnosis at the time

of surgery, and whether patients diagnosed with cancer underwent major surgery related to their

active malignancy "surgery for cancer," or unrelated "surgery with cancer."



Active

Malignancy

Status*

At Risk for

VTE, n (%)




Patients, n (%)

High Moderate Low

Cancer

diagnosis 1868 (30.3) 1350 (72.3)

200

(10.7)291 (15.6)

1377

(73.7)

Surgery for

cancer1767 1295 (73.3)

183

(10.4)267 (15.1)

1317

(74.5)



Factors Associated with the Use of ACCP-recommended VTE Prophylaxis

Operation type was the factor most strongly associated with prophylaxis provision in major surgery patients at

risk for VTE (Fig. 4). When type of surgery was excluded from the multivariable analysis, the comorbidities

commonly associated with the use of prophylaxis were preadmission obesity, in-hospital rheumatologic or

inflammatory disease, preadmission VTE, and presence of a central venous catheter (Fig. 5).

Surgery with

cancer101 55 (54.5)

17

(16.8)24 (23.8) 60 (59.4)

No cancer

diagnosis 4304 (69.7) 2495 (58.0)

470

(10.9)837 (19.4)

2997

(69.6)






Active

Malignancy

Status*

At Risk for

VTE, n (%)




Patients, n (%)

High Moderate Low

Cancer

diagnosis 1868 (30.3) 1350 (72.3)

200

(10.7)291 (15.6)

1377

(73.7)

Surgery for

cancer1767 1295 (73.3)

183

(10.4)267 (15.1)

1317

(74.5)

Surgery with

cancer101 55 (54.5)

17

(16.8)24 (23.8) 60 (59.4)

No cancer

diagnosis 4304 (69.7) 2495 (58.0)

470

(10.9)837 (19.4)

2997

(69.6)






Figure 4. Independent factors associated with the use of ACCP-recommended VTE prophylaxis in

surgical patients at risk for VTE. ACCP indicates American College of Chest Physicians; CCU, critical care

unit; CI, confidence interval; GI, gastrointestinal; ICU, intensive care unit; VTE, venous thromboembolism.



Figure 5. Independent factors, excluding surgery type, associated with the use of ACCP-recommended

VTE prophylaxis in surgical patients at-risk for VTE. ACCP indicates American College of Chest

Physicians; CCU, critical care unit; CI, confidence interval; GI, gastrointestinal; ICU, intensive care unit;

VTE, venous thromboembolism.

Discussion

We found that 93% of patients who underwent a major surgical procedure were at-risk for VTE, with only 62%

receiving ACCP-recommended prophylaxis. Rates of prophylaxis use varied across the participating countries

according to surgery type, and the presence of comorbidities including active malignancy. Major surgery was the

most important factor associated with the use of VTE prophylaxis.

The highest rates of prophylaxis were seen in orthopedic patients. Those undergoing urologic/gynecologic or

other procedures were least likely to receive prophylaxis; approximately half of these patients received no

prophylaxis despite being considered at-risk for VTE.

The proportion of patients undergoing vascular surgery who were considered at-risk for VTE (97.5%) was higher

than published estimates of around 21%.[7] This may result from higher rates of comorbidity in these patients

and the failure to recognize comorbidities which heighten VTE risk.

Our finding that type of operation is the factor most strongly associated with VTE prophylaxis use is consistent

with previous reports.[10,11] Excluding major surgery, obesity was the comorbidity most strongly associated with

the use of prophylaxis. The number of additional risk factors for VTE did not appear to correlate strongly with an

increased use of ACCP-recommended prophylaxis. This apparent lack of an increase in prophylaxis use with

increasing numbers of risk factors may lead to the underuse of prophylaxis in certain patient subgroups, for

example, vascular surgery patients.

Current American Society of Clinical Oncology guidelines on the prevention of VTE in patients with cancer

recommend that all patients with cancer undergoing laparotomy should be considered for pharmacological VTE



prophylaxis in the absence of bleeding or other contraindications.[12] Our findings support the conclusion that

VTE prophylaxis in patients with malignant disease needs to be improved.[12,13]

Due to the cross-sectional study design, duration of prophylaxis could not be recorded. Also, physicians may

have become aware of the study and altered their use of VTE prophylaxis. A further potential limitation is that

data were not collected on the subtype and stage of malignant disease in patients who were diagnosed with

cancer before surgery.

A major strength of this study is that it incorporates data gathered from 32 countries in 6 continents to provide a

truly global view of current VTE prophylaxis practices in surgical inpatients. Unlike previous clinical research

studies or trials which enrolled patients according to the type of surgery performed, this survey included a broad

and real-world sample of patients undergoing a variety of surgical operations.

Conclusions

The ENDORSE surgical population survey highlights the continuing gap between the prevalence of VTE risk in

patients who undergo major surgical procedures and the use of ACCP-recommended prophylaxis. Our

systematic evaluation of the risk for VTE in surgical patients provides improved estimates for both the current

disease burden of VTE and the potential clinical benefits of VTE prophylaxis. These data can also be used to

help guide clinical practice and assist the targeting of guideline dissemination, to improve adherence to existing

recommendations.

References

Kakkar VV, Corrigan T, Spindler J, et al. Efficacy of low doses of heparin in prevention of deep-vein

thrombosis after major surgery. A double-blind, randomized trial. Lancet. 1972;2:101–106.

1.

Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international

multicentre trial. Lancet. 1975;2:45–51.

2.

Sagar S, Massey J, Sanderson JM. Low-dose heparin prophylaxis against fatal pulmonary embolism. Br

Med J. 1975;4:257–259.

3.

Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of

Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6

suppl):381S–453S.

4.

Collins R, Scrimgeour A, Yusuf S, et al. Reduction in fatal pulmonary embolism and venous thrombosis

by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in

general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162–1173.

5.

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP

Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl):338S–400S.

6.

Agnelli G. Prevention of venous thromboembolism in surgical patients. Circulation. 2004;110(24 suppl

1):IV4–IV12.

7.

Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute

hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371:387–

394.

8.

Baglin T, Barrowcliffe TW, Cohen A, et al. Guidelines on the use and monitoring of heparin. Br J

Haematol. 2006;133:19–34.

9.

Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the

1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med.

2000;160:334–340.

10.

Mommertz G, Sigala F, Glowka TR, et al. Differences of venous thromboembolic risks in vascular

general and trauma surgery patients. J Cardiovasc Surg (Torino). 2007;48:727–733.

11.

Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline:

recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin

Oncol. 2007;25:5490–5505.

12.



Acknowledgments The authors thank the physicians and study coordinators participating in ENDORSE, the staff at the Center for Outcomes Research, and Olivia Wu, PhD, Division of Developmental Medicine, University of Glasgow, United Kingdom. ENDORSE is overseen by a medical advisory board of clinicians. A full list of the investigators who participated in ENDORSE, and further information about the registry can be found at http://www.outcomes.org/endorse.

Annals of Surgery. 2010;251(2):330-338. © 2010 Lippincott Williams & Wilkins

Seddighzadeh A, Zurawska U, Shetty R, et al. Venous thromboembolism in patients undergoing surgery:

low rates of prophylaxis and high rates of filter insertion. Thromb Haemost. 2007;98:1220–1225.

13.

Authors and Disclosures

Ajay K. Kakkar, MD, PhD,*† Alexander T. Cohen, MD,‡ Victor F. Tapson, MD,§ Jean-Francois Bergmann,

MD,¶ Samuel Z. Goldhaber, MD,|| Bruno Deslandes,** Wei Huang, MS,†† and Frederick A. Anderson, Jr.,

PhD,†† for the ENDORSE Investigators

*Barts and The London School of Medicine and Dentistry, London, United Kingdom; †Thrombosis Research

Institute, London, United Kingdom; ‡King's College Hospital, London, United Kingdom; §Duke University

Medical Center, Durham, NC; ¶Hôpital Lariboisière, University Paris 7, Paris, France; ||Brigham and Women's

Hospital, Harvard Medical School, Boston, MA; **sanofi-aventis, Paris, France; and ††Department of Surgery,

Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA.

Reprints

Ajay K. Kakkar, MD, PhD, Barts and the London School of Medicine and Dentistry, and Thrombosis Research

Institute, London, SW3 6LR, United Kingdom. E-mail: [email protected].



Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey)

Documents

Transcript of Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey)