Hello, and welcome to the September 2008 venous thrombosis update for the National Blood Clot Alliance (NBCA). This update covers the Surgeon General’s recent Call to Action against DVT and PE, the new ACCP guidelines for clinical practice and an update in CMS policy promoting DVT prophylaxis. Also, Dr. Stephan Moll, a University of North Carolina at Chapel Hill hematologist and Medical Director of NBCA, will discuss who should be considered for testing for clotting disorders.
To begin, there is some great news this month regarding VTE diagnosis, treatment and prevention as the acting surgeon general Dr. Steven K. Galson issued a Call to Action against DVT and PE, advocating the importance of understanding risk factors, associated symptoms and prevention strategies to reduce the number of individuals who develop DVT and PE nationwide. Although this Call to Action does not necessarily mean that the government is going to pay for activities, we, being concerned citizens and affiliates of NBCA, can now tell people that the Surgeon General has formally stated that VTE is a major health issue affecting the American public. This lends even more power to messages aimed at increasing awareness about DVT/PE and highlights the urgency to do something about DVT/PE prevention.
In other health policy news, the American College of Chest Physicians (ACCP) in June published the updated antithrombotic and thrombolytic therapy guidelines. This 1000 page publication is based on clinical studies and covers all aspects of blood clot care, serving as the bible for physicians, hospitals, , and even lawyers. One of its major achievements is that it outlines a formal policy regarding who should be given therapy to prevent DVT . This helps unify DVT treatment across the United States, ensuring that each patient regardless of the institution receives sufficient and up-to-date DVT prevention (termed “DVT prophylaxis”) and antithrombotic care (that is treatment with blood thinning medications). However, should a blood clot occur, the center for Medicare and Medicaid services (CMS) just recently made a decision that they will not reimburse hospitals if a DVT/PE happens to patients following orthopedic total knee or hip replacement surgery. This means that if you get a hip or knee replacement and a week later you develop a DVT/PE and need to be admitted to the hospital, the cost of treatment falls on the hospital. So, it is a big money loss for hospitals, but it will encourage hospitals to give appropriate DVT prophylaxis and, thus, minimize the number of people who develop blood clots. NBCA wrote a position supporting this development, although they felt reimbursement should only be denied if treatment guidelines were not followed because some DVT/PEs are unavoidable. The whole NBCA position statement can be read on NBCA’s website at www.stoptheclot.org.
The new ACCP guidelines state that when a patient is admitted to the hospital for a medical illness, it is important to consider DVT prophylaxis because everyone admitted is at risk for clots. This is true for people with heart failure, severe respiratory disease, and those confined to bed, like most patients are. DVT prophylaxis is highly recommended if the patient has additional risk factors, such as cancer, previous clots, sepsis (that is an infection in the blood stream), stroke, or inflammatory bowel disease. Data suggests that many people do not receive DVT prophylaxis even though the ACCP guidelines recommend it. Consequently, NBCA recommends that patients should be proactive and ask their physician when they get admitted to the hospital: “Should I receive DVT prophylaxis?” In many cases they should.
The second topic about DVT prevention is orthopedic surgery. In hip and knee replacement there is a significant discrepancy between the recommendations of the medical and orthopedic communities. Patients are often caught in the middle, not knowing which of the recommendations should be followed when they undergo surgery. Orthopedist are worried about bleeding after surgery into the orthopedic site, so they like to avoid stronger blood thinners and may use aspirin. Medical people want to be more aggressive than that because they don’t want a DVT or PE to develop.
Thus, there are differences between what the ACCP guidelines say and what the orthopedic community says (AAOS or American Academy of Orthopedic Surgeons). The ACCP recommends LMW heparin at prophylactic doses or warfarin at full dose for 10 days to 5 weeks after the surgery. Aspirin is not mentioned anywhere. Orthopedist believe that for patients at standard risk for blood clots aspirin alone is effective against DVTs, but mentions LMW heparin and warfarin as treatment options. Also, the orthopedic recommendations do not take reference to dosage and duration of prophylactic drugs and treatment. Therefore, for patients it is important to note that there are two conflicting guidelines concerning DVT prevention in total knee and hip replacement. So, talk to your physicians – your internist, orthopedic surgeon, and hematologist – preoperatively and make sure to ask about the type of DVT prophylaxis that will be administered. Ask the physician you trust most to discuss the prophylactic treatment with your other physician, so that everybody is on the line when it comes to how you will be treated after hip and knee replacement.
Testing for blood clotting disorders (thrombophilias). There is no consensus amongst physicians as to who should be tested for clotting disorders. Four guidelines have been written and published over the last 7 years: One from the American College of Medical Geneticists, one from the British Committee for Standards in Haematology, one from the European Genetics Foundation, and one from the Thrombosis Interest Group of Canada. The European guidelines are very liberal, resulting in widespread testing, while the British are quite conservative. The Americans and Canadians fall between these groups. So, there is no general consensus and many different opinions exist on who should be tested. Unfortunately, this lack of guidance from respected medical authorities sometimes leads to an insecurity by practicing physicians as to which patient and family members should really be tested for thrombophilia, This sometimes results in indiscriminate testing. Very frequently, finding a clotting disorder does not influence a patients medical management, such as the length of treatment with a blood thinner, so the question could be asked why test for one?
For example, studies have shown that finding that finding the inherited clotting disorder factor V Leiden – the most common thrombophilia -, in a patient who has had a blood clot in the veins, i.e. a deep vein thrombosis or pulmonary embolism (DVT and PE)- does not influence decisions on length of warfarin. “But wouldn’t it be beneficial for family members of a patient with a blood clot to know whether they may have a clotting disorder? Couldn’t they then be proactive to avoid blood clots?” Everybody should be proactive; everybody should try to modify his/her risk factors for DVT and PE: normalize weight, be physically active, stop smoking, be considered for DVT prophylaxis if hospitalized or undergoing major surgery, be aware of the risk of blood clots with birth control pills and other hormone therapy.
In addition, everybody should know the symptoms of DVT and PE. Patients may say “but I want to know why I clotted”. But finding one of the common clotting disorders may give a false sense of knowledge, because just having, for example, the clotting disorder Factor V Leiden does not really fully explain the clot, as many people have Factor V Leiden and never clot. There are situations, where it may be reasonable to investigate a patient for underlying clotting disorders. A publication this month by Dr. Stephan Moll, NBCA’s Medical Director in the September 2008 issue of Advances in Haemtatology discusses this complex topic, including the existing guidelines. It also tries to give some guidance on thrombophilia testing to the healthcare providers who encounters patients with deep vein thrombosis and pulmonary embolism.
Thank you for listening to the September 2008 update in venous thrombosis news and research presented by the National Blood Clot Alliance. We hope you join NBCA and the Surgeon General in the effort to raise awareness, educate and protect the American people against venous blood clots. And remember, patient advocacy and education is our top priority, so please inform us of any suggestions you may have to help make this podcast more educational. You can send your suggestions to NBCApodcast@gmail.com. That is spelled N-A-T-T-P-O-D-C-A-S-T@G-M-A-I-L.com. There is still much to do and NBCA greatly needs your support.
Posted November 11, 2008
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