Lack of Thromboprophylaxis Across the Care Continuum in US Medical Patients

Venous thromboembolism (VTE) prophylaxis is suboptimal, with many at-risk medical patients not receiving anticoagulants in hospital. Among those who receive anticoagulants in the hospital, thromboprophylaxis is frequently stopped at discharge despite persistent risk. Few studies have investigated prophylaxis use across the continuum of care. We analyzed anticoagulant use in medical patients in hospital and after discharge. Patient records (January 2005-December 2007) from medical patients with cancer, heart failure, severe lung disease, or infectious disease who were deemed at risk for VTE by the 2008 American College of Chest Physicians guidelines were included. Records were queried for inpatient and outpatient anticoagulant use by cross-matching data from the Premier Perspective discharge database with the i3/Ingenix LabRx outpatient and inpatient database. Of the 9675 medical patients identified, only 36.1% received inpatient anticoagulation (24.9% cancer patients, 30.1% infectious disease patients, 42.5% severe lung disease patients, and 56.3% heart failure patients). Of those who received in-hospital anticoagulants, most received enoxaparin (58.6%) followed by unfractionated heparin and other prophylactic agents. Only 1.8% of medical patients were prescribed anticoagulants within 30 days after discharge, ranging from 1.1% of patients with infectious disease to 4.8% of patients with heart failure. The majority of patients discharged who received outpatient anticoagulation filled prescriptions for warfarin, followed by enoxaparin plus warfarin. This real-world study demonstrates that only one-third of at-risk medical patients receive anticoagulants in hospital, with < 2% continuing to receive prophylaxis after discharge. Therefore, there is a need to improve the provision of thromboprophylaxis in the continuum of care for acutely ill medical patients.