Clinical outcomes and adherence to guideline recommendations during the initial treatment of acute venous thromboembolism.
BACKGROUND
Adherence to American College of Chest Physicians (CHEST) guidelines for treatment of acute venous thromboembolism (VTE) has not been formally assessed in the United States, specifically in the subset of patients with renal impairment.


OBJECTIVE
Evaluate adherence to CHEST VTE treatment guidelines.


METHODS
This retrospective cohort study evaluated patients with acute VTE between January 1, 2010, and December 31, 2011, for the primary outcome of adherence to CHEST VTE treatment guidelines defined as (1) patients receiving an appropriate parenteral anticoagulant and dose based on renal function and weight, (2) at least 5 days of parenteral anticoagulation during warfarin initiation, and (3) an international normalized ratio (INR) value ≥2 documented before discontinuing parenteral agents. Secondary outcomes included recurrent thromboembolism and major bleeding across renal function categories.


RESULTS
Of the 1683 patients included in the final analysis, 1483 (88%) had complete data for all 3 elements of the primary outcome (dose, overlap duration, and INR ≥2.0). VTE guideline adherence was identified in 95% (1408/1483) of these patients. There were 20 major bleeds overall, which occurred in 1.1%, 1.1%, and 1.3% in patients with CrCl <30 mL/min, 30 to 59 mL/min, and ≥60 mL/min, respectively (P = 0.929). Also, 7 recurrent VTE events occurred-3 in patients with CrCl values of 30 to 59 mL/min (0.5%) and 4 in patients with CrCl ≥60 mL/min (0.4%; P = 0.797 across groups).


CONCLUSIONS
Adherence to CHEST guidelines was high and resulted in low rates of bleeding and recurrent VTE complications across renal function categories. Further studies of patients with CrCl <30 mL/min are needed.
Kaiser Permanente Colorado, Aurora, CO, USA Kerri.D.Martinez@kp.org.
Kerri
K
Martinez
Kaiser Permanente Colorado, Aurora, CO, USA Salud Family Health Centers and University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
Emily
E
Kosirog
Kaiser Permanente Colorado, Aurora, CO, USA.
Sarah J
SJ
Billups
Kaiser Permanente Colorado, Aurora, CO, USA.
Nathan P
NP
Clark
Kaiser Permanente Colorado, Aurora, CO, USA.
Thomas
T
Delate
University of Utah College of Pharmacy, Salt Lake City, UT, USA.
Daniel M
DM
Witt
D000208:Acute Disease; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D005260:Female; D019983:Guideline Adherence; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012008:Recurrence; D051437:Renal Insufficiency / Q000150:complications; D012189:Retrospective Studies; D014481:United States; D054556:Venous Thromboembolism / Q000150:complications / Q000188:drug therapy*; D014859:Warfarin / Q000627:therapeutic use
D000925:Anticoagulants; D014859:Warfarin
anticoagulant drugs; evidence-based practice; guideline adherence; pharmacist; pharmacist-managed service; practice guideline; renal insufficiency; venous thromboembolism