Abstract
Introduction
Despite the importance of Venous Thromboembolism (VTE) prophylaxis in hospitalized patients, audits have shown inadequate use of VTE prophylaxis methods around the world. We aimed to assess knowledge, attitudes, and behaviors regarding VTE prophylaxis among clinicians in Nepal.
Methodology
A cross-sectional questionnaire-based survey was conducted using an online survey platform.
Results
199 (60.7%) of the respondents were aware of the risk factors-based risk stratification approach to VTE prophylaxis in hospitalized patients. Only 154 (47%) of the physicians reported institute-based protocols for VTE prophylaxis.
Conclusion
We found a significant lack of awareness on risk factors-based stratification strategy for VTE prevention practices among Nepalese physicians. We recommend educational efforts for Nepalese physicians on the overall impact of VTE on mortality and morbidity of hospitalized patients. Our study highlights the needs for adoption of institution-based protocols for VTE prophylaxis and prevention.
Keywords: Venous thromboembolism, Prophylaxis, Hospitalized patients, Nepal, VTE risk stratification
1. Introduction
Venous thromboembolism (VTE) is a leading cause of preventable hospital deaths. Healthcare-associated VTE-related morbidity and mortality is a public health problem1 but is preventable with appropriate use of anticoagulants and or use of compression stockings, however, fewer than half of patients receive these interventions.2 Inpatient VTE prophylaxis has received increased attention from the agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS) over the last decade.3 The American College of Chest Physician (ACCP) guidelines are the most commonly followed protocols for inpatient VTE prophylaxis management.4 Despite the availability of such guidelines, audits have shown inadequate use of VTE prophylaxis methods in hospitalized patients.5
Several earlier studies have suggested the possibility of lower susceptibility and incidence of VTE in Asian population. However, newer data show a similar rate of VTE after major surgery and in medical patients among Asian population compared to the Western populations. VTE is increasing across Asia due to several factors including an aging population, increasing number of complex surgeries, higher rates of cesarean deliveries, rising obesity, increasing incidence of cancers, and low rates of chemoprophylaxis.6 There is very little published data on the VTE prophylaxis methods being adopted in Nepal, and it is unclear if there is any consensus on the protocols being followed for VTE prophylaxis in the country. This study aimed to explore the comprehension and practice of VTE prophylaxis among physicians in Nepal.
2. Materials and methods
A cross-sectional survey was designed to assess the knowledge of VTE prophylaxis among clinicians in Nepal. We collected data using an online survey platform (Survey Monkey). Additionally, using the principles of snowballing, the link was circulated by the investigators through social media for capturing data.
The survey was anonymous, with no names or other identifying data. The period of data collection was between July 14, 2019, till August 13, 2019. A total of 331 questionnaires were collected, 3 questionnaires were partially filled and were excluded from the final analysis. We collected information from the participants including:
Level of Medical Degree (medical school vs postgraduate training)
Physician’s prior experience with VTE events and VTE related mortality
Use of Institution-based protocol for VTE and doctor’s belief in such protocol
Risk stratification based on risk factors
Prophylaxis methods used for each risk group
Physician’s beliefs regarding the incidence of VTE in Nepalese population and need for prophylaxis
Concerns regarding pharmacological prophylaxis
Physician’s beliefs on how to raise awareness among medical professionals regarding VTE
The collected data was analyzed using descriptive statistics. Statistical analyses were performed with SPSS Version 21.
3. Results
The majority of our respondents were medical school graduates practicing independently (291 out of 328, 88.7%) and worked in medical wards (231 or 74%) (See Table 1). 246 (75%) of respondents had encountered VTE in their clinical practice while 87 (35.37%) of the participants reported encountering VTE-related mortality. 60.7% of the respondents were aware of the risk factors-based risk stratification approach to VTE prophylaxis in hospitalized patients. It was interesting to know that 101 (30.8%) of the respondents did not have any idea about the risk stratification for VTE, and among them, 95 were medical school graduates with no specialty training (See Fig. 1). 73% of clinicians with postgraduate training were well acquainted with risk stratification whereas only 59.1% of medical school graduates were aware of risk stratification strategies.
Table 1.
Demographic profile of participants in the study.
| Female | Male | Total | ||
|---|---|---|---|---|
| Highest level of education | MBBS | 122 | 169 | 291 |
| MD | 15 | 22 | 37 | |
| Predominant place of work | Medical floor/ward | 99 | 135 | |
| Surgical floor/ward | 13 | 38 | ||
| Medical ICU | 16 | 28 | ||
| Surgical ICU | 5 | 18 | ||
| Orthopedics floor | 6 | 16 | ||
| Obstetrics/Gynecology floor | 22 | 6 | ||
| Other departments | 28 | 34 |
MBBS: Bachelor of Medicine, Bachelor of Surgery; MD: Doctor of Medicine; ICU: Intensive Care Unit.
Fig. 1.
Knowledge on risk-stratification for Venous thromboembolism prophylaxis.
292 (89%) reported the use of pharmacologic prophylaxis for VTE with the highest use proportion reported in ICU set up. However, only 81.8% reported using VTE chemoprophylaxis in the Orthopedics department. LMW Heparin was the most commonly used chemoprophylaxis agent for VTE prophylaxis (68.6%), followed by Heparin (35%) and factor Xa inhibitors (20%) while only Aspirin use was reported by 27.7% of the respondents (See Table 2). The risk of bleeding was seen as a major concern for VTE prophylaxis use by 77.7% of the participants followed by cost (29.8%) (See Fig. 2).
Table 2.
Venous Thromboembolism (VTE) in clinical picture.
| No | Yes | Total | ||
|---|---|---|---|---|
| VTE Encounter in Clinical Practice | 82 (25%) | 246 (75%) | 328 | |
| VTE-Mortality | ||||
| Encounter in Clinical Practice | 159 (64.63%) | 87 (35.37%) | 246 | |
| Institute-Based | ||||
| Protocol for VTE | 174 (53.0%) | 154 (47.0%) | 328 | |
| Prophylaxis | ||||
| Use of any drug for pharmacological prophylaxis of VTE | Medical Ward | 32 (13.7%) | 202 (86.3%) | 234 |
| Surgical Ward | 4 (7.8%) | 47 (92.2%) | 51 | |
| Medical ICU | 2 (4.5%) | 42 (95.5%) | 44 | |
| Surgical ICU | 2 (8.7%) | 21 (91.3%) | 23 | |
| Orthopedic Ward | 4 (18.2%) | 18 (81.8%) | 22 | |
| Obstetrics/Gynecology/Ward | 4 (14.3%) | 24 (85.7%) | 28 | |
| Other Departments | 6 (9.7%) | 56 (90.3%) | 62 | |
| Agents for Pharmacological VTE Prophylaxis | Use of any drug | 36 (11.0%) | 292 (89.0%) | 328 |
| Aspirin | 237 (72.3%) | 91 (27.7%) | 328 | |
| Heparin | 213 (64.9%) | 115 (35.1%) | 328 | |
| Low Molecular Weight Heparin | 103 (31.4%) | 225 (68.6%) | 328 | |
| Factor Xa Inhibitors | 308 (93.9%) | 20 (6.1%) | 328 | |
| Other drugs | 321 (97.9%) | 7 (2.1%) | 328 | |
Fig. 2.
Concerns with use of Venous thromboembolism prophylaxis.
We found that only 206 (62.8%) percent of the physicians used a combination of mechanical and pharmacological means for DVT prophylaxis in high-risk patients (See Table 3). Only 154 (47%) of the physicians reported institute-based protocols for VTE prophylaxis in their hospitals (See Table 2). Significant proportions of the physician didn’t believe either problem-based learning in medical schools (56%) or workshops (60.7%) and institutional policy (59.1%) helps increase the awareness of VTE prophylaxis among physicians (See Fig. 3).
Table 3.
Assessment of knowledge on Venous Thromboembolism (VTE).
| No specific | Mechanical | Heparin + Related Products | Mechanical + Pharmacological | Total | |
|---|---|---|---|---|---|
| VTE Prophylaxis (Low Risk Patients) | 70 (21.3%) | 121 (36.9%) | 103 (31.4%) | 34 (10.4%) | 328 |
| VTE Prophylaxis (High Risk Patients) | 7 (2.1%) | 4 (1.2%) | 111 (33.8%) | 206 (62.8%) | 328 |
Fig. 3.
Interventions to improve Venous thromboembolism prophylaxis.
4. Discussion
A. Incidence of VTE events:
The majority of the respondents were not aware of the incidence of VTE events in Nepalese population. Most participants had no idea if Nepalese population is more susceptible to VTE than white or Caucasians. On review of literature, we were not able to find any studies on the incidence of VTE events in the Nepalese population. A smaller study done in Eastern Nepal involving 66 patients with hip fracture, showed DVT in 5 patients (8%); however, the study evaluated only clinical signs of DVT for diagnosis, which is likely to miss asymptomatic cases.7
Traditionally, Asian population has been considered to be at low risk of VTE events compared to the Western population.8 A retrospective study in Pakistan reported the prevalence of VTE in postoperative patients as 5.6/10,000 despite pharmacological thromboprophylaxis being used in only 24% of the patients.9 Another study from India, however, reported the incidence of VTE at 17.46 per 10,000 admissions.10 A systematic review by Lee et al. reported annual incidence of VTE at 15–20% of the levels recorded in the Western population but also notes that the incidence is increasing.11 It is noteworthy that most of this data is derived from countries like South Korea, Taiwan, Hongkong with a relatively higher standard of medical practice compared to south Asian countries with low gross domestic product (GDP) including Nepal. However, the SMART study, a prospective observational study in Asian population, showed a comparable incidence of DVT between Asian and Western populations in patients undergoing orthopedic surgery.12
In our study 75% of the respondents reported encountering at least one VTE event in their clinical practice and 35.3% reported encountering VTE-related mortality with the highest percentage reported in ICU setting and surgical units. This suggests that the risk of VTE events in Nepalese population is not lower than others. This further highlight lack of data on the burden of VTE in Nepalese population. This knowledge gap should be addressed with further studies.
B. Knowledge and practices on Risk Stratification and VTE chemoprophylaxis:
We found a significant lack of awareness on risk factors-based risk stratification for VTE events and appropriate guidelines-based VTE prevention practices among Nepalese physicians. Physicians without postgraduate training knew less about VTE risk stratification in comparison to medical school graduates with a difference of 14% (73% vs 59.1%). It is noteworthy that all medical school graduates can independently practice after completing one year of compulsory internship. The lack in VTE prevention practices can be attributed to lack of adequate education on VTE prophylaxis in medical school.
A significant proportion of the respondents did not believe either problem-based learning in medical schools or workshops and institutional policy can increase the awareness of VTE prophylaxis among physicians. ACCP recommends thromboprophylaxis based on risk stratification for prevention of VTE in hospital admitted patients and emphasizes on the adoption of VTE protocol by all institutes. ACCP advocates using risk stratification tools such as Capriani and Rogers score in non-orthopedic surgical patients and Padua Prediction Score risk assessment model in non-surgical patients to guide clinicians’ decision to initiate chemoprophylaxis.13 Despite multiple VTE prophylaxis guidelines, the rate of utilization of these measures worldwide remains low as highlighted by a multinational ENDORSE study.5 Data on the practice of VTE prophylaxis in Nepalese hospital is lacking. We found only one cross-sectional study from a teaching hospital in Nepal that reported 58% (40/69) of patients eligible for VTE chemoprophylaxis did not receive any prophylaxis.14
Studies have shown inconsistent and inappropriate VTE prophylaxis practices even in developed countries. A large Canadian study showed that only 16% of hospitalized patients who had indications for thromboprophylaxis received appropriate prophylaxis.15 The reported use of thromboprophylaxis by clinicians in Nepal in our study is higher than the reported use in Western countries. However, this result should be cautiously interpreted, as it was difficult to confirm the actual usage of thromboprophylaxis due to the lack of Electronic Medical Records (EMR) in Nepal.16
C. Interventions to increase VTE Risk assessment and thromboprophylaxis:
VTE prevention is key in reducing VTE-related morbidity and mortality in hospitalized patients and overall healthcare costs.17 We have noticed in our study that 51.8% of the physicians felt they needed institute-based protocol for VTE prophylaxis but only 47% reported having such protocol at workplace. It has been well accepted that implementation of effective protocols can minimize the incidence of healthcare-acquired VTE. The protocol-driven approach for VTE prophylaxis needs to be bolstered by using a quality improvement framework, a multidisciplinary team approach, and ongoing monitoring of the process.18
Several institutions in the United States reported decreased rates of VTE events after implementation of mandatory risk stratification.19,20 It is noteworthy that clinical decision support systems were utilized in those institutions. Computerized clinical decision support and mandatory tools integrated into provider workflows such as alerts and can be more effective than passive ones such as continuing education, dissemination of guidelines, audit, and feedback.21,22 In a developing nation like Nepal, it would be logistically and financially difficult to provide such active tools based on information technology, where EMR is still not widely adopted.
4.1. Limitations of the study
We adopted a questionnaire-based interview strategy which is at risk for reporting bias. Due to lack of EMR, the actual data in clinical practice couldn’t be ascertained to correlate with reported data. A significant number of participants in our study were medical school graduates with no specialty training. This could have skewed our data as specialty-trained physicians could have a better understanding of the risk stratification process and appropriate use of VTE prophylaxis.
Most of the participants in our study were working in medical units. The units with a higher risk of DVT including surgical and intensive care units (ICUs) represent only a small portion of the data. The information collected needs to be analyzed with caution as surgical units and ICUs are more likely to house patients with a higher risk of VTE events.
5. Conclusion
Our study highlighted a significant lack of knowledge and expertise on evidence based VTE prophylaxis in hospitalized patients among Nepalese physicians. We found that Nepalese health institutions lack institutional protocols and guidelines for VTE prophylaxis in hospitalized patients. Furthermore, there is limited data on the burden and susceptibility of VTE events among Nepalese population, leading to failure of appraisal of the huge public health cost associated with VTE. We recommend educational efforts for Nepalese physicians on the overall impact of VTE on mortality and morbidity of hospitalized patients. We advocate for adoption of institution-based protocols for VTE prophylaxis and prevention in Nepal.
Footnotes
6. Disclaimer
All authors vouch for the originality of this work and confirm that this work or manuscript has not been submitted to any other journal for publication consideration.
7. Financial disclosure
All authors declare that they do not have any financial disclosure to disclose. None of the authors have received any grants or support from any entities for this work or any other work.
References
- 1. Beckman MG, Critchley SE, Hooper WC, Grant AM, Kulkarni R. CDC division of blood disorders: public health research activities in venous thromboembolism. Arterioscler Thromb Vasc Biol. 2008;28(3):394–395. doi: 10.1161/ATVBAHA.108.162453. [DOI] [PubMed] [Google Scholar]
- 2. Zeidan AM, Streiff MB, Lau BD, et al. Impact of a venous thromboembolism prophylaxis “smart order set”: improved compliance, fewer events. Am J Hematol. 2013;88(7):545–549. doi: 10.1002/ajh.23450. [DOI] [PubMed] [Google Scholar]
- 3. Streiff MB, Brady JP, Grant AM, et al. CDC Grand Rounds: preventing hospital-associated venous thromboembolism. MMWR Morbidity and Mortality Weekly Report. 2014;63(9):190–193. http://www.ncbi.nlm.nih.gov/pubmed/24598595%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4584727 . [PMC free article] [PubMed] [Google Scholar]
- 4. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 suppl L):e227S–e277S. doi: 10.1378/chest.11-2297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387–394. doi: 10.1016/S0140-6736(08)60202-0. [DOI] [PubMed] [Google Scholar]
- 6. Liew NC, Alemany Gv, Angchaisuksiri P, et al. Asian venous thromboembolism guidelines: updated recommendations for the prevention of venous thromboembolism. Int Angiol. 2017;36(1):1–20. doi: 10.23736/S0392-9590.16.03765-2. [DOI] [PubMed] [Google Scholar]
- 7. Pokhrel B, Poudel S, lal Shah L. Incidence of deep vein thrombosis following hip fracture surgery at Tribhuvan University Teaching Hospital. J Chitwan Med College. 2018;8(2):10–15. https://www.nepjol.info/index.php/JCMC/article/view/23731 . [Google Scholar]
- 8. Angchaisuksiri P. Venous thromboembolism in Asia–an unrecognised and under-treated problem? Thromb Haemostasis. 2011;106(4):585–590. doi: 10.1160/TH11-03-0184. [DOI] [PubMed] [Google Scholar]
- 9. Edeer AD, Comez S, Damar HT, Savci A. Prevalence and risk factors of venous thromboembolism in postoperative patients: a retrospective study. Pakistan J Med Sci. 2018;34(6):1539–1544. doi: 10.12669/pjms.346.16021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Lee AD, Stephen E, Agarwal S, Premkumar P. Venous thrombo-embolism in India. Eur J Vasc Endovasc Surg. 2009;37(4):482–485. doi: 10.1016/j.ejvs.2008.11.031. [DOI] [PubMed] [Google Scholar]
- 11. Lee LH, Gallus A, Jindal R, Wang C, Wu CC. Incidence of venous thromboembolism in Asian populations: a systematic review. Thromb Haemostasis. 2017;117(12):2243–2260. doi: 10.1160/TH17-02-0134. [DOI] [PubMed] [Google Scholar]
- 12. Leizorovicz A, Turpie AGG, Cohen AT, Wong L, Yoo MC, Dans A. Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART Study. J Thromb Haemostasis. 2005;3(1):28–34. doi: 10.1111/j.1538-7836.2004.01094.x. [DOI] [PubMed] [Google Scholar]
- 13. Henke PK, Kahn SR, Pannucci CJ, et al. Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association. Circulation. 2020:E914–E931. doi: 10.1161/CIR.0000000000000769. . Published online. [DOI] [PubMed] [Google Scholar]
- 14. Paudel U, Bhatt PR, Nepal C. Use of thromboprophylaxis for venous thromboembolism among patients admitted in medical ward. J Patan Acad Health Sci. 2019;6(1):83–88. doi: 10.3126/jpahs.v6i1.27087. [DOI] [Google Scholar]
- 15. Kahn S, Panju A, Geerts W, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res. 2007;119(2):144–155. doi: 10.1016/j.thromres.2006.01.011. [DOI] [PubMed] [Google Scholar]
- 16. Raut A, Yarbrough C, Singh V, et al. Design and implementation of an affordable, public sector electronic medical record in rural Nepal. J Innovat Health Inf. 2017;24(2):862. doi: 10.14236/jhi.v24i2.862. . Published 2017 Jun 23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Depietri L, Marietta M, Scarlini S, et al. Clinical impact of application of risk assessment models (Padua Prediction Score and Improve Bleeding Score) on venous thromboembolism, major hemorrhage and health expenditure associated with pharmacologic VTE prophylaxis: a “real life” prospective and re. Intern Emerg Med. 2018;13(4):527–534. doi: 10.1007/s11739-018-1808-z. [DOI] [PubMed] [Google Scholar]
- 18. Sr K, Diendéré G, Piché A, et al. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2013;7 doi: 10.1002/14651858.CD008201.pub3CD008201-CD. Published online 2018 www.cochranelibrary.com. [DOI] [PubMed] [Google Scholar]
- 19. Haut ER, Lau BD, Kraenzlin FS, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147(10):901–907. doi: 10.1001/archsurg.2012.2024. [DOI] [PubMed] [Google Scholar]
- 20. Turrentine FE, Sohn MW, Wilson SL, et al. Fewer thromboembolic events after implementation of a venous thromboembolism risk stratification tool. J Surg Res. 2018;225:148–156. doi: 10.1016/J.JSS.2018.01.013. [DOI] [PubMed] [Google Scholar]
- 21. Kahn SR, Morrison DR, Diendéré G, et al. Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2018;4(4) doi: 10.1002/14651858.CD008201.PUB3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open. 2016;6(9):e012555. doi: 10.1136/bmjopen-2016-012. [DOI] [PMC free article] [PubMed] [Google Scholar]