Coagulation Counseling

DECEMBER 01, 2008
Anna D. Garrett, PharmD, BCPS, CPP

Dr. Garrett is manager of the Health Education Center at Mission Hospitals in Asheville, North Carolina.

LMWH Lowers DVT Risk After Arthroscopic Surgery

A recent study of patients undergoing arthroscopic knee surgery showed a decrease in deep vein thrombosis (DVT) in patients who were treated with prophylactic low-molecularweight heparin (LMWH) for 7 or 14 days after surgery. Investigators randomized 1761 patients who underwent knee arthroscopy in an Italian clinic to wear full-length graduated compression stockings for 7 days or to receive daily subcutaneous LMWH for 7 or 14 days.

After 3 months, the incidence of the primary efficacy endpoint—asymptomatic proximal DVT, proximal or distal symptomatic DVT, or death from any cause—was significantly lower in the LMWH groups (0.9% in both the 7- and 14-day groups) than in the stocking group (3.2%). These primary endpoint events were more common in patients who underwent meniscectomy than in those who underwent diagnostic arthroscopic procedures or surgeries not involving meniscus removal.

Acting Surgeon General Issues Call to Action

Acting Surgeon General Steven K. Galson, MD, MPH, has issued a call to action to reduce the number of cases of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the United States. DVT and PE affect an estimated 350,000 to 600,000 Americans each year. Together, DVT and PE contribute to at least 100,000 deaths each year.

The call to action urges a coordinated, multifaceted plan to reduce the numbers of cases of DVT and PE nationwide. The plan emphasizes the need for:

  • Increased awareness about DVT and PE
  • Evidence-based practices for DVT
  • More research on the causes, prevention, and treatment of DVT

The call to action resulted from a Surgeon General's Workshop on DVT that was convened in May 2006. The complete document is available at:

Low-Dose Aspirin Helps Prevent Clots in PV

Polycythemia vera (PV) and essential thrombocytosis (ET) are chronic disorders with an increased risk of arterial and venous thrombosis, as well as bleeding.

Based on the estimated individual risk of thrombotic and bleeding complications, different therapeutic strategies are available: phlebotomy for PV or platelet apheresis for ET, or drug therapy (eg, hydroxyurea, anagrelide, interferon alpha) and aspirin to prevent platelet aggregation. Long-term administration of aspirin is associated with an increased risk of major upper gastrointestinal bleeding and hemorrhagic stroke, however.

The efficacy of low-dose aspirin has been studied in PV, and, given the evidence, it appears that the risk of bleeding is outweighed by the benefit of a reduction in fatal thrombotic events when compared with placebo. No increased risk of major bleeding was noted. Therefore, low-dose aspirin is recommended for patients with PV and no contraindications to therapy. No studies on the effects of low-dose aspirin in patients with ET have been published.

CMS Adds Postoperative DVT/PE to List of "Never Events"

The Centers for Medicare & Medicaid Services (CMS) announced that it is taking several actions to improve the quality of care in hospitals and reduce the number of preventable medical errors that result in serious consequences for the patient.

Numerous studies have documented the detrimental effects on patients and the increased costs of health care services resulting from a patient's preventable injury or condition acquired due to hospital errors.

These can include "never events"—those events that never should occur—like amputation of the wrong limb or transfusing patients with the wrong blood type.

CMS is working with the National Quality Forum (NQF)—a national organization acting to promote patient safety and improve hospital care—on ways to reduce or eliminate 28 Never Events identified by NQF.

Among the newest group of Never Events is deep vein thrombosis (DVT) or pulmonary embolism (PE) after total knee or total hip replacement surgery. The new ruling means that CMS will not pay facilities for additional costs incurred as a result of the event. CMS has determined that DVT/PE is reasonably preventable with proper care.

In addition to the final rule, CMS sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. The letter specifically encourages states to adopt the same nonpayment policies outlined in the final Medicare rule.

Nearly 20 states already have or are considering methods to eliminate payment for some never events. The final rule is effective for discharges after October 1, 2008.