Transcript VTE - SpeakerLink

Venous Thromboembolism (VTE)
A patient safety issue from a patient perspective
Beth Waldron, MA
Program Director, Clot Connect
University of North Carolina at Chapel Hill
April 16, 2012
NCD HENS Partnership for Patients Webinar
Disclosures
Beth Waldron
None
Clot Connect Program
Cooperative Agreement with CDC
Educational charitable donations by
Talecris Biotherapeutics
NC Cancer Hospital Endowment Fund
Agenda
1.
2.
3.
4.
5.
VTE background
Patient story
VTE prevention in hospital setting
VTE resources
Discussion
Terminology
Deep Vein Thrombosis (DVT):
 Clot that has formed in the deep veins of
the body, also called Deep Vein Thrombosis,
or DVT
 While DVT can occur anywhere in the body,
it is most common in the leg.
Pulmonary Embolism (PE):
 Clot in the pulmonary vessels, often
referred to as PE.
 PE occurs when a blood clot breaks off from
a DVT, travels through the blood stream and
lodges in the lung.
 Potentially life-threatening complication of
DVT.
Venous Thromboembolism (VTE):
 DVT + PE are collectively known as VTE
QUESTION:
Who is at increased risk for VTE?
A. 70 year old man in good general health
B. 40 year old athletic man having knee surgery
C. 30 year old cancer patient on chemotherapy
D. 20 year old healthy pregnant woman
E. None of the above
F. All of the above
Factors which increase VTE risk
 Immobility (during hospitalization, recovery at home)
 Major surgery (abdomen, pelvis, hip, knee)
 Bone fracture or cast
 Central venous catheter
 Increased estrogen (birth control pill/patch/ring, pregnancy, hormone
therapy)
 Certain medical conditions (cancer and its treatment, heart failure,
inflammatory disorders)
 History of VTE; family history of VTE
* multiplicative risk
 Clotting disorder (thrombophilia)
 Obesity
 Smoking
95% of hospital patients = at risk
31% of hospital patients = moderate to high risk
 Age
Anderson et al. 2007 AHRQ HCUP Discharge data
VTE: A patient safety issue
Approximately 300,000-600,000 Americans develop VTE each year. 1
60,000-100,000 die each year from VTE.
Many deaths from PE go undiagnosed. Actual figure may be higher.
40% of all VTE are associated with hospitalization 2
 occurring either in the hospital or shortly after discharge
VTE is one of the leading preventable causes of hospital death 3
40% or more of hospital associated VTE is preventable through prophylaxis 4
Sources:
1 CDC
2 Heit 2012
3 AHRQ
4 PfP
VTE: Not a benign event for patients and family
Sudden death occurs in 25% of patients with pulmonary embolism 1
Post-thrombotic syndrome (PTS)
Occurs in 40-50% of DVT survivors 2
Characterized by chronic swelling, pain, decreased mobility, ulceration
Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
Occurs in 4% of PE survivors 3
Characterized by persistent shortness of breath, particularly with
exercise, which can lead to right-side heart failure
 High levels of anxiety, depression and psychological stress have been
reported among VTE patients 4
Sources:
1 CDC
2 Ashrani/Heit 2009; Kahn et al 2008
3 Pengo et al. 2004
4 Lui et al 2011; Lukas et al 2009
VTE: Not a benign event for hospitals or society
Estimates:
$10 billion in medical costs each year due to VTE (United States) 1
Total medical cost per DVT per patient per year = $19,800 (US 2010)2
Among health plan members with a first time VTE hospitalization, 25%
had hospital readmission with an average cost of $15,000 3
Appropriate prophylaxis can reduce hospital costs by as much as
$2,000 per high risk patient 4
Sources:
1 CDC-NCBDDD Strategic Plan 2011
2 Mahan et al. 2011
3 Spyropoulos & Lin 2007
4 Amin et al 2011
A patient’s clotting story…my story
 2003, 34 years old, married, 1 child:
 Diagnosed with DVT and bilateral PE
 Prior to clotting episode:
 Excellent health
 No notable medical conditions
 No recent travel, surgery, or hospitalization
 Medications: recently restarted oral
contraceptives following 4 year break
Mike, Beth & Evan Waldron
My story: Missed opportunities for diagnosis
Symptoms:
Initial diagnosis:
Leg pain
pulled muscle
Chest pain+
Rapid heart rate+
Shortness of breath
respiratory infection - prescribed antibiotics
Symptoms of VTE can mimic other less serious conditions, delaying accurate diagnosis
Result:
Leading to:
Second PE episode
9 day hospitalization
surgical placement of inferior vena cava filter
initiation of anticoagulant therapy
IV heparin
Subcutaneous low-molecular weight heparin
warfarin (Coumadin®)
My story: Outcome
My risk factors for clotting at the time of diagnosis:
 Genetic thrombophilia identified (homozygous Factor V Leiden mutation)
 Oral contraceptives ?
 ???
 multiplicative risk
Today:
Long-term anticoagulant therapy
No new clots
Mild post-thrombotic syndrome
Lifelong worry of recurrence
Motivated to prevent and reduce
burden of VTE!!
Story Takeaway:
From the patient perspective, VTE is a major event
For VTE survivors:
 Risks associated with anticoagulant use, bleeding risk
 Burden of anticoagulation, management/monitoring
 Pain management
 Mobility concerns
 Development of post-thrombotic disorders, possible disability
 Higher risk for clot recurrence
 Psychological effects associated with a life-threatening and
lifestyle-altering medical condition
 Cost of care: both short-term acute management and long-term
follow-up care
Prevention, prevention, prevention!!!
If you prevent the VTE, you prevent the negative outcomes.
VTE Prevention
Much is known about how to prevent VTE,
but that knowledge is not being applied in a consistent, systemic way.
Guidelines for Hospital Prevention of VTE:
American College of Chest Physicians (ACCP) 9th edition, 2012
American College of Physicians (ACP) November 2011
American Academy of Orthopedic Surgeons (AAOS), September 2011
American College of Obstetricians and Gynecologists (ACOG), September 2011
American Society of Clinical Oncology (ASCO) 2007
National Comprehensive Cancer Network (NCCN) 2010
VTE risk assessment
prophylaxis
Pharmacologic – anticoagulant
Mechanical - compression device,
graduated compression stockings
Weighing VTE risk with bleeding risk associated with anticoagulants
Challenges in reducing hospital associated VTE:
Limited use of prophylaxis
Prophylaxis may be given too late, for too short a duration, or
in less than optimal dose or form
 Inconsistent application of guidelines
Variance by facility, provider specialty, individual physician,
surgical procedure, inpatient/outpatient, medical/surgical
A need exists for:
1.
2.
3.
4.
Standardized VTE risk assessment
Adherence to standards
Consistent application of policies, VTE prevention measures
Health care professionals fully engaged in VTE prevention at their
hospital.
 Knowledge: understand the impact it has on patient safety and
optimal health outcomes
 Empowerment: provided the tools and resources to have impact
VTE Resource
.org
 Outreach initiative at the University of North
Carolina in Chapel Hill
 Mission: to increase knowledge of VTE,
thrombophilia and anticoagulation by providing
education and support resources for patients and
health care professionals
Clot Connect initiatives are targeted at:
Persons who have experienced VTE
Persons at high risk for developing VTE
Health care professionals
www.ClotConnect.org
For Patients…
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
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Education materials, videos, webinars
Education blog answering common questions and concerns
Online support forum
Monthly newsletter
www.ClotConnect.org
For Health Care Professionals…
Access to clinical care guidelines
Patient handout materials
Education blog to assist with clinical care and anticoagulation management
Monthly newsletter
www.ClotConnect.org
Summary
VTE: A patient safety issue from a patient perspective
VTE is a major patient safety issue.
VTE can occur in anyone, at any age.
VTE is not a benign medical event---impact on patients and hospitals.
VTE can be prevented.
40% or more of VTE is preventable through prophylaxis.
Key to reducing hospital-associated VTE:
Vigilance to consistently assess all hospitalized patients for VTE risk and
implement proper prophylaxis measures.
Key to reduce complications of VTE:
 Patients should be aware of the symptoms of DVT and PE and know
what to do/who to call should symptoms arise following discharge.
Contact information:
Beth Waldron
Program Director, Clot Connect
University of North Carolina at Chapel Hill
CB 7305
170 Manning Dr-3185K Physician Office Building
Chapel Hill, NC 27599-7305
919-966-2809
[email protected]
www.ClotConnect.org