Tuesday, November 08, 2011

The American College of Physicians weighs in on VTE prophylaxis for hospitalized medical patients

---with a systematic review published in the Annals of Internal Medicine alongside a new set of guidelines. This has caused a bit of a stir, so is it anything really new? Yes and no.

First, the systematic review indicates that any benefits from prophylaxis are much, much more modest than popularly believed, particularly considering associated bleeding risks.

The guidelines themselves are being spun as a new and more restrictive approach to VTE prophylaxis. However, they are not fundamentally different from the Chest guidelines, which reserve prophylaxis in medical patients for those with increased VTE risk who do not have high bleeding risk. In contrast to the Chest guidelines, the ACP document is less specific as to what conditions constitute increased clotting or bleeding risk, and makes the statement that no risk assessment tools have been validated.

What is new in the ACP guidelines is the strong statement that recommendations for VTE prophylaxis should not be used as a performance measure. Many of these measures make pharmacologic prophylaxis the default option which may be embedded in order sets of electronic medical records. The point is that pharmacologic VTE prophylaxis should not be given by default, but for specific indications taking into account individual patient attributes.

I applaud this statement by the ACP. They recognize the toxic effects of performance measures, and how they can limit the effectiveness of evidence based care.