“clinical practice pathways”; while “computerized electronic alerts” as well as “algorithm-based” strategies were widely developed to ensure continued compliance.
Another important, yet unspoken, factor that may have augmented this response was the federal government’s Centers for Medicare and Medicaid Services (CMS) threat to deny reimbursement for hospital-acquired VTE as it considered it a “preventable medical error”. Compliance with these guidelines (which the CMS presumed would eliminate such “preventable medical errors”) was therefore viewed as an important means towards improving patients’ outcomes, decreasing “preventable medical errors” and avoiding potential penalties. Such eagerness for “perfect compliance” was fostered and patrolled by hospital administrators and quality control medical officers. One wonders if this could have led to a speedy generalization of the recommendations to include some patients that may have been at extraordinarily low risk for VTE or unusually high risk for bleeding complications. Therefore, the “Sentinel Event Alert” released by The Joint Commission entitled “Preventing Errors Relating to Commonly Used Anticoagulants”) in late 2008 came as no surprise to us.
Reconciling the Newly Adopted ACCP Outcome Measures with Daily Practice The ACCP methodologists attempted to weigh the evidence for and against thromboprophylaxis using prevention of fatal PE and “symptomatic” VTE (which they presumed to be synonymous with “clinically relevant” VTE) as the primary goal of this treatment, while at the same time integrating serious bleeding complications into the final outcome. Interestingly, in order to justify this “new” endpoint, they considered asymptomatic, venographically-confirmed VTE to be clinically irrelevant and, therefore, could be discounted from the evidence. Needless to say, the arguments against using the disputed terms symptomatic/clinically relevant and asymptomatic/clinically irrelevant interchangeably are obvious to every practicing clinician and well summarized in the paper by Bounameaux and Agnelli.
In my opinion, the advantages of advancing the discussion about VTE prophylaxis practices as universal recommendation are many. It certainly highlights the importance of thoughtfully considering the risks and benefits of pharmacoprophylaxis in every hospitalized patient and removing the automation from the process. The limitations inherent in the historical studies used by the authors as basis for their recommendation (whether supporting “symptomatic” or disputing “asymptomatic” events) call for expanding funding for larger, well conducted prospective studies that address these issues directly. Further research focused on improving clinically-accepted means of enhanced profiling of thrombotic as well as bleeding risks in profiling of hospitalized patients are also needed.
Conclusions Clinical guidelines are meant to raise awareness and highlight the public health impact as well as establish a framework for approaching a specific clinical problem. Clinical judgment and individualized risk assessment remain the most critical component of decision making, and this is particularly true when it comes to VTE prophylaxis.