The roundtable, produced in collaboration with Haymarket Medical Education, is directed to hospitalists, on preventing, diagnosing, and treating venous thromboembolism (VTE). The interdisciplinary faculty will identify the barriers to adopting appropriate best practices regarding VTE prophylaxis and management. The ultimate goal of the program is to improve health outcomes of hospitalized patients at high risk of VTE and for ensuring continuity of care once they are discharged from the hospital. This peer-to-peer interaction offers practical insights and empowers viewing hospitalists to make changes that might result in better overall outcomes for inpatients at risk of VTE.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), affects almost 3 million people annual.¹ PE occurs in 600,000 people and DVT occurs in 2 million people annually.¹ Prevention is critical because of the first symptom may be death.^2,3 Many of the acquired VTE risks, such as hospitalization, surgical procedures, obesity, increasing age, and chronic disease, are increasing among the US population. For inpatients, additional risk factors for VTE include active cancer and recent immobilization or bed rest.⁴

Despite the reduced survival after PE-and the availability of guidelines from major medical organizations-not all clinicians and institutions follow recommendations to prevent and treat VTE.^5-8 And ongoing multinational study comparing the antithrombotic therapy practices of 52 randomly selected hospitals found that patients received mechanical or pharmacologic VTE prophylaxis only half the time, and of those patients, only 12% were discharged with adequate prophylaxis.⁹ In the United States, 33% of patients received either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH), compared with 47% of patients in other countries.⁹ Hospitalists, in addition to their role in preventing and managing VTE, have a significant responsibility in educating patients discharged from the hospital on the benefits of anticogulant therapy following initial management of VTE.

Current guidelines from the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) recommend using validated prediction rules to estimate the pretest probability of VTE before performing more definitive testing on patients who present with symptoms of FVT or PE.⁷ For diagnosed DVT, the AAFP/ACP guidelines recommend administering bleeding and mortality.⁸ Newly updated guidelines for outpatient management of anticoagulation therapy, published in June 2008 by the American College of Chest Physicians (ACCP), call for treatment of objectivity confirmed DVT or PE with LMWH, UFH, or fonffaparinux.⁵ Notably, the ACCP guidelines recommend treatment with anticogulants for patients with a high clinical suspicion of DVT or PE while awaiting the outcome of diagnostic tests.

VTE is a leading cause of reduced survival in hospitalized patients, particularly those undergoing major surgery.^10-13 Such surgery carries an especially high risk for VTE because of postoperative immobility and traumatic effects of surgery on the coagulation system.^10-14 However, the problem of VTE is not limited to surgical patients only, as evidenced by the fact that most cases of VTE and most fatal causes of VTE occur among hospitalized medical patients.¹⁵

The patients today are discharged from the hospitals as early as possible underscores the need for hospitalists to stay current on the latest guidelines for VTE recognition, prevention, and treatment, and to take a lead in their institutions by evaluating all patients for VTE risk factors, and to educate patients about the importance of appropriate therapy and prevention strategies at home.¹⁴

1. Jaffer AK. An overview of venous thromboembolism: impact, risks, and issues in prophylaxis. Cleve Clin J Med. 2008;5(suppl 3):S3-S6.
    
2. Heit JA. Venous thromboembolism epidemiology: implications for prevention and management. Semin Thromb Hemost. 2002;28(suppl 2):3-13.
    
3. Heit JA, Cohen AT, Anderson FA Jr. Estimated annual number of incident and recurent, non-fatal and fatal venous thromboembolism (VTE) events in the US. Blood. 2005;106:abstract 910:267a.
    
4. Segal JB, Eng J, Tamariz LJ, Bass EB. Review of the evidence on diagnosis of deep venous thromosis and pulmonary embolism. Ann Fam Med. 2007;5:63-73.
    
5. Kearon C. Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 supp1):454S-545S.
    
6. Tapson VF, Hyers TM, Waldo AL, et al; NABOR (National Anticoagulation Benchmark and Outcomes Report) Steering Committee. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med. 2005;165;1458-1464.
    
7. Qaseem A, Snow V, Barry P, et al; Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and American College of Physicians. Ann Intern Med. 2007;146:454-458.
    
8. Snow V, Qaseem A, Barry P, et al; The Joint American College of Physicians/American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Fam Med. 2007;5:74-80.
    
9. Tapson VF, Decousus H, Pini M, et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the international medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132:936-945.
    
10. Clagett GP, Anderson FA, Heit J, et al. Prevention of venous thromboembolism. Chest. 1995;108:312S-334S.
     
11. National Institutes of Health Consensus Development Conference. Prevention of venous thromboembolism. JAMA. 1986;256:744-749
     
12. Haake DA, Berkman SA. Venous disease after hip surgery. Risk factors, prophylaxis, and diagnosis. Clin Orthop. 1989;242:212-231.
     
13. Scott TE, LaMorte WW, Forin DR, et al. Risk factors for chronic venous insufficiency: a dual case-control study. J Vasc Surg. 1995;22:622-628.
     
14. Bhattacharyya T, Iorio R, Healy WL. Rate of and risk factors for acute inpatient mortaility after orthopaedic surgery. J Bone Joint Surg Am. 2002;84:562-572.
     
15. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl):381S-453S.

This CME activity is intended for hospitalists

Upon completion of this educational activity, participants should be able ti:

• Define the health and economic burdon of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), in inpatient settings.
• Recognize the institutional challenges to adopt VTE prophylaxis and treatment protocols and develop quality improvement team strategies for deployment of these protocols.
• Attain greater proficiency in diagnosing hospitalized patients at risk of VTE prevention options.
• Devise a formal VTE recognition and prophylaxis program in practice, including the education of high-risk patients.

Ian Jenkins, MD (Chair)
Associate Professor of Medicine
Department of Internal Medicine
University of California, San Diego
San Diego, CA

David A. Garcia, MD
Associate professor
Department of Internal Medicine
University of New Mexico School of Medicine
Albuquerque, NM

Michael H. Huo, MD
Professor, Department of Orthopedic Surgery
UT Southwestern Medical School
Dallas, TX

Amir K. Jaffer, MD
Associate Professor of Medicine
Chief, Division of Hospital Medicine
Service Chief, Medicine
Lenoard M. MIller School of Medicine
University of Miami
Miami, FL

Victor F. Tapson, MD
Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Medicine Director of Pulmonary Hypertension Center
Duke University Medical Center
Durham, NC

COURSE DIRECTOR

Henny H. Billett, MD
Professor of Clinical Medicine and Pathology
Albert Einstein College of Medicine
Director of Clinical Hematology
Weiler/Einstein Hospital
Bronx, NY
 

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians and other health-care providers.

Albert Einstein College of Medicine designates this educational activity for a maximum of 2.5 AMA PRA Category 1 credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

There are no fees for participating and receiving CME credit for this activity. During the period June 1, 2010 through May 31, 2011, participants must:

• Register for the program where prompted on the CD
• Complete the posttest by recording the best answer to each question in the answer key
• Complete the activity evaluation form
• Submit directly online

A statement of credit will be issued immediately online only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better.

Estimated time to complete this activity: 2.5 hours

The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any presenter whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity, or who refuses to provide all their conflict-of-interest information, will not be permitted to present.

Disclosures

Ian Jenkins, MD, is on the speakers’ bureau for Medavera.

David A. Garcia, MD, receives grant/research support from Bristol-Myers Squibb and Boehringer Ingelheim. He is a consultant for Bristol-Myers Squibb and Boehringer Ingelheim.

Michael H. Huo, MD, is a consultant for sanofi-aventis, Cadence Pharmaceuticals, Stryker, and Boehringer Ingelheim. He is on the speakers’ bureaus for sanofi-aventis and King Pharmaceuticals.

Amir K. Jaffer, MD, receives grant/research support from AstraZeneca. He is a consultant for Daiichi Sankyo and Canyon Pharmaceuticals.

Victor F. Tapson, MD, is a consultant for Boehringer Ingelheim and sanofi-aventis. He receives grant/research support from Bayer and sanofi-aventis.

Melissa Johnson and Suzanne Bujara of Haymarket Medical Education have nothing to disclose.

Henny H. Billett, MD, has nothing to disclose.
 

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA.

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of the patients' conditions, review of any applicable manufacturers' product information, and comparison with recommendations of recognized authorities.

The information in this program is provided to medical professionals for information purposes only.

The material contained herein is intended to be a faithful representation of the live presentations to the extent reasonable. The authors/presenters are exclusively responsible for the respective content. Accordingly, no responsibility is assumed by sanofi-aventis, Albert Einstein College of Medicine of Yeshiva University, Haymarket Medical Education LP, or Scientia MedMedia LLC, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise; or from any use of diagnosis or treatment discussed or suggested. This activity should not be used by clinicians without medically appropriate (1) evaluation of (a) their patients' conditions and (b) indications and possible contraindications, warnings, and adverse effects or dangers in use; (2) review of any applicable manufacturers' prescribing and other product information; (3) comparison with recommendations of recognized authorities; and (4) independent verification of diagnostic methods, therapeutic methods, results of research, and measurement of medical doses.