VTE prophylaxis for medical patients when they leave hospital: a wider approach to future research and evidence is required

Editor – Clinical Medicine has published a summary of the National Institute for Health and Care Excellence (NICE) NG89 recommendations on venous thromboembolism (VTE) prophylaxis.^1,2 Subsequently the guidance for pharmacological prophylaxis for a minimum of 7 days for medical inpatients who are at high risk has been challenged by haematologists both for effectiveness and cost effectiveness when the patient has been discharged before this course length has been completed.^3,4 In the last edition of Clinical Medicine, Thomas et al estimated the drug related costs of this aspect of the guidance for patients who would require ongoing prophylaxis post discharge, but they were unable to estimate the cost for district nursing support for those who could not self administer.⁵

The Royal College of Physicians' Patient Safety Committee considered the implications of this element of the guidance in 2018 and concluded that the level of evidence was unclear and that implementation of the guidance across medical practice currently in the NHS did not include continuation of pharmacological prophylaxis post discharge. This was communicated to NICE. Given reducing lengths of stay in hospital, increasing community support for patients who are immobilised during acute illness, we believe that ‘hospitalisation’ as a marker of risk for VTE in acute medical illness is a rather blunt risk factor. Future research should consider the patients risk overall, at home or in hospital. Cost effectiveness of pharmacological intervention must include support care costs for patients who are unable to manage this therapy and the risks of polypharmacy in this cohort.