VTE - prevention and treatment

1. How can VTE be prevented?
2. How is VTE treated?
3. Is universal prophylaxis cost-effective?
4. What are the VTE expert guidelines?
5. What are the barriers to implementing guidelines?
6. What are the recommendations from governments?
7. Why should VTE be viewed as a major public health issue in the 25 European countries?
8. What are the major VTE challenges in Europe?
References


1. How can VTE be prevented?
VTE is a preventable condition and there are several ways to prevent its occurrence. Preventive treatments for deep-vein thrombosis (DVT) include early mobilization after surgery, graduated compression stockings, sequential compression devices, venous foot pumps and blood-thinning drugs (usually anticoagulant drugs). Mechanical devices are suitable for preventing DVT in persons with a high risk of bleeding. Otherwise, blood-thinning drugs are commonly used to prevent blood clots from forming, and so reduce the risk of VTE – this therapy is called thromboprophylaxis. Clinical guidelines, namely those of the American College of Chest Physicians (ACCP), (updated in 2004 based on the results from recent clinical trials) are available with recommendations for therapies that can prevent the occurrence of VTE. As pulmonary embolism (PE) is the most common cause of preventable hospital death, and PE prevention is the number 1 strategy for improving patient safety in the hospital, specific recommendations are provided to advise which groups of hospital patients should receive prophylaxis, how it should be provided, and the type of drug that should be used. Prevention of VTE is particularly important in anyone who has a serious illness or condition that restricts mobility.1
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2. How is VTE treated?
A range of treatment strategies are available to treat VTE. These include mechanical devices such as graduated elastic compression stockings and pneumatic compression boots when the patient is hospitalized; anticoagulants, such as unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) or oral anticoagulants; and thrombolytic therapy (a clot buster used for severe PE). Treatment preferentially involves the combination of a mechanical device and pharmacological treatment with anticoagulant therapy. Although both UFH and warfarin have been used for over 50 years for the treatment of VTE, more recently LMWHs have been replacing the traditional agents for the initial treatment of VTE. New clinical data suggest that some patients with DVT can be treated with LMWH in an out-patient setting; this may provide a more convenient and economical way of managing patients with VTE.2
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3. Is universal prophylaxis cost-effective?
VTE is a costly condition and imparts a significant economic burden on healthcare systems. Thromboprophylaxis can reduce both the incidence of VTE and the continuing burden of costly complications in VTE management. This is because smaller doses than those used to treat VTE can be given, and there is less risk of bleeding. Debilitating post-thrombotic syndrome (PTS) is among the most significant and costly long-term health complications of DVT, and occurs in 20–60% of people with symptomatic DVT; 5–10% of these patients have severe PTS.3 A more convenient and economical way of managing patients with DVT and preventing PE may also be to reduce the length of hospital stay required for treatment. Emerging clinical data suggest that hospital stay can be reduced 5-fold in certain patients with DVT treated with LMWH compared to those receiving standard treatment with UFH, and may provide a suitable cost-effective alternative for patients at risk of VTE.2 
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4. What are the VTE expert guidelines?
The VTE expert guidelines are a set of comprehensive and evidence-based recommendations on the most effective way to prevent and treat VTE. The latest guidelines from ACCP are generally considered to be the standard of care for DVT and for the prevention of PE. The ACCP recommends thromboprophylaxis with LMWH or low-dose UFH for the prevention of VTE in general medical patients with clinical risk factors such as cancer, bed-rest, heart failure and severe lung disease.3
In the UK, the House of Commons Health Committee issued a report in 2005 on the prevention of VTE in hospitalized patients, with specific recommendations on how to increase awareness of VTE as a major public health problem. The government responded to this report by requesting and recommending specific action points, such as commission guidelines by NICE (available at http://nice.org.uk since 23 April 2007). The Chief Medical Officer wrote to all doctors to remind them of the existing guidance and set up an independent Expert Working Group. In France, a public health objective of lowering VTE by 15% in 2008 has been passed by the French Senate.4 In 2007, there was still a need to further improve the French epidemiological data, increase patient and physician educational activities, and amplify the lobbying activities of physicians and/or medical societies. In Germany, there were several activities in 2007 aiming to increase awareness of the problem of VTE and initiate public-relation and educational activities. The German association of scientific medical societies developed and implemented guidelines to prevent, diagnose, and treat VTE. There has also been considerable interaction between this association and healthcare providers, policy-makers, the media, and pharmaceutical companies to discuss scientific issues around VTE. In the USA, a coalition has been established with the objectives of reducing the immediate and long-term dangers of VTE and educating the public, healthcare professionals, and policy- makers about risk factors, symptoms, and signs associated with DVT. This coalition consists of 50 members, mainly healthcare professionals' associations and national healthcare organizations. In 2007, the coalition managed to achieve: almost one billion “media impressions” to date that reach each American more than 3 times; a “Call to Action” for DVT by the Office of the Surgeon General; an endorsement of consensus standards for VTE prevention and care by the National Quality Forum; and  a test of these measure by the Joint Commission.
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5. What are the barriers to implementing guidelines?
Implementation of internationally accepted evidence-based guideline recommendations remains suboptimal. Barriers to guideline implementation are physician-related, environmental- and guideline-related. Physician-related barriers arise because VTE is often a secondary diagnosis and not perceived as an important issue. There is also a perceived difficulty of risk assessment and a lack of awareness about guidelines and clinical studies that recommend thromboprophylaxis based on evidence of proven efficacy and safety. Improvement in education and systematically providing thromboprophylaxis to high-risk patients could overcome these barriers. Environmental-related factors include time limitations, staff shortages, cost concerns, and poor reimbursement, which reflect a lack of knowledge of the benefits of VTE prevention on patient outcome and hospital costs. The main guideline-related barriers are the lack of consensus on recommendations, which are often due to differences in local practice, and the time-lag in updating recommendations in line with new evidence from clinical studies. 
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6. What are the recommendations from governments?
To date, very few governments have taken measures to make VTE prevention a public health priority in the campaign to reduce the disease and economic burden. The UK Expert Working Group set up by the government requested mandatory VTE risk assessment of all hospitalized patients and recommended that thromboprophylaxis be considered for all medical and intermediate-risk surgical patients; that high-risk surgical patients to be managed according to guidelines; that core standards be set by the department of health to ensure compliance and education of healthcare professional and patients; and that strategy outcomes be evaluated.⁵ In France, the Senate has passed a public health objective of lowering VTE by 15% in 2008.⁴ In Germany, several expert groups (e.g. hospital doctors, policy-makers, physician associations, healthcare providers, the media, and the pharmaceutical industry) decided to bring the problem of VTE to the attention of the Ministry of Health via discussion and activities of the German association of scientific medical societies, the German Chamber of Physicians, and the leading local groups from each federal state. The role of patient associations in providing an interface between health professionals and public health authorities to increase awareness of the need for VTE prevention should be encouraged and supported in all countries.
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7. Why should VTE be viewed as a major public health issue in the 25 European countries?
Data from the VITAE study confirm that VTE needs to be viewed as a major public health issue with an estimated EU incidence of 0.7 million DVT, 0.4 million PE events and 500,000 deaths annually.6 VTE is currently an enormous burden in the EU – there is a very large and increasing at-risk population who would benefit from effective preventive strategies. These strategies could prevent VTE events, save lives, reduce the high risk of mortality associated with VTE and lower the cost of treating patients with VTE – particularly in those with long-term complications. Currently, thromboprophylaxis is not widely practiced, despite the evidence-based recommendations for more widespread systematic use of effective VTE prophylaxis including LMWH or UFH to prevent VTE and reduce the economic and societal burden.^1,2 In surgical cases, prophylaxis is more commonly seen as essential, and current guidelines include recommendations. For medical patients, however, many guidelines currently do not specify what, if any, prophylaxis should be given for prevention of VTE-associated events.
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8. What are the major VTE challenges in Europe?
To obtain a better standard of care for VTE prevention, the major VTE challenges are to accelerate awareness of the extent of the VTE problem in Europe, ensure systematic assessment of the risk of VTE, and take a proactive approach to VTE prevention at individual, national, and European levels. Information campaigns and targeted educational programmes are needed to sound the alert about the risk of VTE and raise awareness of the benefits of VTE prevention. Individuals need to be informed about simple lifestyle changes and other effective preventive measures that can reduce the risk of VTE. Health professionals should ensure that guidelines and recommendations on VTE prevention are implemented in clinical practice. Decision-makers and stakeholders in the healthcare sector should be aware of the health and cost benefits of VTE prevention and make it a public health priority. To respond to these challenges, it is necessary to make a noise about VTE, an often silent but deadly disease that can be avoided with effective prophylaxis.
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References
Geerts WH, Pineo GF, Heit JA et al. Prevention of venous thromboembolism. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S
Levine M et al. N Engl J Med 1996;334:677-81
Kahn S et al. Arch Intern Med 2004;164:17-26
Sénat. Loi n 2004-806 relative à la politique de santé publique. www.senat.fr. “Thromboses veineuses profondes”. Accessed 21 September 2005
House of Commons Health Committee Report on the Prevention of Venous Thromboembolism in Hospitalised Patients. Available at: www.publications.parliament.uk/pa/cm200405/cmselect/ cmhealth/99/9902.html. Accessed 19 September 2005
Cohen AT et al. Thromb Haemost. 2007;98:756-64