Too few get vet­ted for clot­ting risk

The Weekend Australian - Travel - - Health - Adam Cress­well

EX­PERTS have urged fed­eral, state and ter­ri­tory gov­ern­ments to en­sure hos­pi­tals as­sess ev­ery pa­tient’s risk of de­vel­op­ing po­ten­tially fa­tal blood clots af­ter an in­ter­na­tional study found fewer than half those at risk were re­ceiv­ing pre­ven­tive treat­ments.

Health de­part­ments in NSW and Queens­land have al­ready adopted new guide­lines on pre­vent­ing clots, and the trans-Tas­man work­ing party that drew them up is call­ing on other states to fol­low suit.

The Aus­tralia and New Zealand Work­ing Party on the Pre­ven­tion of Ve­nous Throm­boem­bolism (VTE) says VTE, the tech­ni­cal term for clots that form in the veins, is a lead­ing cause of pre­ventable hospi­tal deaths, killing up to 10,000 peo­ple in Aus­tralian hos­pi­tals each year.

VTEs can be fa­tal if they travel to the lungs, where they can lodge and block blood flow. Th­ese cases, known as pul­monary em­boli, are es­ti­mated to be re­spon­si­ble for 10 per cent of hospi­tal deaths.

Pro­fes­sor John Fletcher, chair­man of the work­ing party, said the num­ber of lives taken by VTE was greater than the num­ber of lives taken by lung can­cer and breast can­cer com­bined.

‘‘ Hos­pi­tals can and should be tak­ing rou­tine steps to im­ple­ment bet­ter qual­ity and safety mea­sures to pre­vent blood clots in pa­tients as a mat­ter of pri­or­ity,’’ Fletcher said.

Just two weeks ago The Aus­tralian re­ported (Fe­bru­ary 7) that a study in The Lancet had found that while half of Aus­tralian hospi­tal pa­tients ad­mit­ted for non­sur­gi­cal treat­ments were at risk of VTE, just 42 per cent of that num­ber re­ceived pre­ven­tive treat­ments.

The in­ter­na­tional study ( Lancet 2008;371:387-94) in­volved nearly 70,000 hospi­tal pa­tients in 32 coun­tries — in­clud­ing 1200 pa­tients at eight hos­pi­tals in Aus­tralia.

While VTE risk has been widely recog­nised in sur­gi­cal pa­tients, the med­i­cal com­mu­nity has been slower to take the risk se­ri­ously in med­i­cal pa­tients, who are ad­mit­ted for treat­ment of var­i­ous con­di­tions not re­quir­ing surgery, said Alex Gal­lus, the co-or­di­na­tor of the Aus­tralian arm of the study and pro­fes­sor of haema­tol­ogy at Flin­ders Univer­sity.

Th­ese pa­tients in­clude those ad­mit­ted for treat­ment of heart at­tack and stroke, lung dis­eases, can­cer and other con­di­tions.

Al­though 49 per cent (406) of the 834 Aus­tralian med­i­cal pa­tients in the study were judged to be at risk of VTE, only 51 per cent (208) of those 406 were given any pre­ven­tive treat­ments.

An even lower num­ber — 42 per cent (172) of the 406 — re­ceived the pre­ven­tive treat­ments in ac­cor­dance with in­ter­na­tional guide­lines.

Pre­vent­ing VTE can be achieved by var­i­ous means, in­clud­ing limb move­ment — as ad­vised on air­line flights — com­pres­sion stock­ings or anti-clot­ting drugs.

Gal­lus said while the latest guide­lines were ‘‘ evo­lu­tion­ary’’ rather than dra­mat­i­cally dif­fer­ent from pre­vi­ous ver­sions, the ev­i­dence for the risk in med­i­cal pa­tients had be­come much more con­crete in re­cent years. This made it vi­tal that the guide­lines were prop­erly ap­plied, he said.

‘‘ Un­less you have a mech­a­nism that is part of the hospi­tal sys­tem that in­cludes the risk as­sess­ment, peo­ple (on hospi­tal staff) won’t nec­es­sar­ily do it,’’ he said.

‘‘ And if they don’t do it, they will ei­ther ap­ply pro­phy­laxis in an in­dis­crim­i­nate way, and use it when it’s not needed as well as not use it when it is, or they won’t use it at all.

‘‘ Un­less you build that (as­sess­ment) into the sys­tem, it just doesn’t work well.’’

The Lancet study was funded by drug gi­ant Sanofi-Aven­tis, which makes one of the drugs used to pre­vent and treat VTE. How­ever, Gal­lus said many of the older an­ti­co­ag­u­lant drugs were rel­a­tively cheap — cost­ing about $1 per day — and in re­peated stud­ies had been shown to be cost-ef­fec­tive.

Gal­lus said the is­sue was im­por­tant, but it had to be re­mem­bered that while pul­monary em­boli were re­spon­si­ble for up to 10 per cent of hospi­tal deaths, many of th­ese pa­tients were se­ri­ously ill with can­cer or other dis­eases and pre­vent­ing the clot would not mean­ing­fully ex­tend their lives.

‘‘ It’s not go­ing to be 5 or 10 per cent of deaths that you pre­vent (by pre­vent­ing VTE),’’ he said. ‘‘ But it might be 1 or 2 per cent of deaths that you pre­vent, which is still a large num­ber across the na­tion.’’

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