Editor – You recently published an article1 summarising the new recommendations for medical inpatients within the updated National Institute for Health and Care Excellence (NICE) venous thromboembolism (VTE) prevention guidelines.2 We welcome the opportunity to highlight a major concern with regards to these recommendations, which affect every patient over the age of 16 admitted to hospital.
The guidelines recommend offering ‘pharmacological VTE prophylaxis for a minimum of 7 days to [medical and the majority of surgical patients] whose risk of VTE outweighs their risk of bleeding.’ In reply to concerns raised at consultation, it was stated that the NICE committee agreed that there was limited evidence for the most effective duration of low molecular weight heparin (LMWH) in these patients and 7 days was the average duration of LMWH in the clinical trials evaluated throughout the guideline. Clinical practice has changed significantly in the 20 years since these trials were published and the populations in these clinical trials were highly selected, with prolonged medical inpatients stays and at higher risk of VTE than the majority of current medical admissions.3,4 The median length-of-stay for acute medical inpatients in our hospitals is 2 days and using the Department of Health VTE tool the majority of these patients are currently prescribed pharmacological thromboprophylaxis only while an inpatient. There is currently no evidence to support this group of patients having a further 5 days of LMWH prophylaxis at home. There would be additional significant cost to the NHS in dispensing time, sharps bins/disposal/training, resources of district nurses (the latter required for 20–30% of patients), and drug costs; without an evidence base for benefit/harm in this setting.
A survey of National VTE Exemplar Centres in October 2018 found that 95% (n=24) reported not adopting this new recommendation (in a personal communication of Roopen Arya accepted for publication). If we do not challenge NICE guidance where recommendations are based on limited data, then we disservice patients through the provision of non-evidence-based interventions requiring reallocation of scarce resources.
References
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- 2.National Institute for Health and Care Excellence Venous thromboembolism in over 16s; reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline [NG89]. London: NICE, 2018. www.nice.org.uk/guidance/ng89 [Accessed 21 March 2019]. [PubMed] [Google Scholar]
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