Background: Venous thromboembolism (VTE) poses a significant risk to patients in the hospital setting, and studies have shown that VTE prophylaxis should be incorporated into the management of high-risk patients during their hospital stay. However, many of these patients are still high-risk for VTE at the time of discharge and for up to three months after discharge. In fact, 50% of VTE events occur approximately 30 days after hospital discharge. Despite this reality, patients are often discharged home without any form of VTE prophylaxis. Two recent studies, the MARINER trial and the APEX trial, revealed evidence that certain novel oral anticoagulants (NOACs) are safe and efficacious for extended VTE prophylaxis in this population of patients. The MARINER trial investigated the use of Rivaroxaban, and the APEX trial evaluated Betrixaban. Both of these drugs were found to be beneficial as VTE prophylaxis in the month following hospital discharge. With this information in mind, we chose to examine the patients discharged from our institution’s hospitals who were still considered high-risk for VTE at the time of hospital discharge, based on three different risk assessments – the Padua score, the Geneva score, and the IMPROVE score. Our aim is to identify a need for change in hospital discharge protocols to reduce the incidence of VTE events among non-ICU, medically ill patients hospitalized at our healthcare system by focusing on extended prophylaxis for patients discharged from our hospitals.
Methods: This retrospective study utilized data that was collected from patients admitted to the medical service in 2019. Patients that were excluded were those who expired during their hospitalization. The patients were evaluated using three different VTE risk scales, IMPROVE, Padua, and Geneva. Each patient was evaluated using all three scoring systems to determine their risk for VTE at time of discharge.
Results: At the time of hospital discharge, 56% of patients were at high-risk for VTE, indicated by a Padua Score ≥ 4. 78% of patients were at high-risk for VTE based on a Geneva Score ≥ 3 at discharge. Additionally, 24% of patients were at high-risk for VTE at time of discharge with an IMPROVE Score ≥ 3. For each of these scoring systems, a patient that is considered high-risk is indicated for VTE prophylaxis.
Conclusions: Patients are at high risk for VTE during hospital stays, and this risk often remains elevated even after discharge. However, many of these at-risk patients are sent home without any form of extended VTE prophylaxis. Our investigation revealed that there is a need for continued prophylaxis after discharge. Anywhere from 24-78% of the patients we included in our study were still at high-risk for VTE at the time of discharge, based on three different risk assessment tools, which is an indication for VTE prophylaxis. Based on this information and the results of the APEX and MARINER trials, our recommendation is to implement a new protocol at our institution that requires patients with a high-risk score for VTE to receive extended prophylaxis upon discharge, either with Rivaroxaban or Betrixaban.