Standards for VTE published in new report

February 19, 2007

Practitioners will now have access to consensus standards for the treatment of venous thromboembolism (VTE). The National Quality Forum (NQF) has announced publication of a new report, National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Policy, Preferred Practices, and Initial Performance Measures.

According to the group, VTE, which includes both deep vein thrombosis and pulmonary embolism, is the most common preventable cause of hospital death and occurs in about 900,000 Americans each year. To combat this problem, NQF has endorsed 20 consensus standards-one statement of policy, 17 key characteristics of preferred practices, and two performance measures.

According to Gladys H. Mitani, Pharm.D., associate professor of clinical pharmacy at the University of Southern California School of Pharmacy, the importance of consensus standards lies in their ability to increase awareness and recognition of the problem and its complications. "They establish a plan and set guidelines to help identify patients at risk, improve outcomes related to VTE complications, and reduce treatment failures," she explained. "They also save lives."

In fact, one performance measure in the new report is that surgery patients have the recommended VTE prophylaxis ordered. The other measure for institutions is to ensure surgery patients receive appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

Among the 17 preferred practices highlighted in the consensus statement are several that focus directly on treatment and monitoring recommendations. According to Mitani, protocols should cover assessment of patients for bleeding risk as well as set initial doses for anticoagulation preparations and for timing and monitoring of laboratory values after initial doses and change in dosage. The NQF report also called for guideline-directed therapy that includes duration of heparin/oral anticoagulation overlap and total duration of therapy.

"Protocols should cover how the patient is monitored, including laboratory parameters," Mitani said. "Guidelines should include monitoring for heparin-induced thrombocytopenia [HIT] and what to do in case platelet counts fall and HIT is suspected or actually develops," she added. The guide also suggests institutions spell out the appropriate indications for placement and retrieval of an IVC (inferior vena cava) filter, thrombolytic therapy, prevention of postthrombotic syndrome and venous embolectomy, and monitoring for the development of chronic thromboembolic pulmonary hypertension.

Another key characteristic of preferred practice is to provide patients with accurate verbal and written education appropriate to the setting and patient reading levels, a practice that is especially important, NQF emphasized, for outpatients. This is one area in which pharmacists can get involved. Pharmacists can also develop protocols that identify patients at risk for VTE, initiate and monitor therapy, and identify factors that can interfere with therapeutic response to anticoagulants or increase the risk of bleeding-such as the concurrent use of antiplatelet agents, explained Mitani.

Although not specifically mentioned in the NQF report, genetic genotyping may also become an important factor in the future, Mitani believes. "Each protocol for a given facility will need to ensure that the appropriate laboratory is used to monitor the different antithrombotic therapies and that the therapeutic targets are appropriate," she said.

In addition to the NQF guide, new clinical practice guidelines for the management of VTE were jointly released in January by the American Academy of Family Physicians and the American College of Physicians. These guidelines called for the use of low molecular weight heparin for outpatients with deep vein thrombosis when proper support services are in place. This document can be accessed on-line at http://www.annals.org/.

The executive summary of the NQF report and the list of measures can be found on the NQF Web site at http://www.qualityforum.org/.