Select Committee on Health Minutes of Evidence


Memorandum by Lifeblood: the Thrombosis Charity (VT 6)

  Lifeblood: the thrombosis charity was born out of frustration caused by the lack of awareness of thrombosis, especially venous thromboembolism (VTE). VTE is a life-threatening disorder and is the commonest preventable cause of hospital mortality. VTE is easily prevented, but prevention depends on both patients and health professionals being aware of this condition. Thus it is critical to heighten this awareness.

  We are extremely grateful to the members of the Health Select committee for organising this enquiry, which we in Lifeblood believe is much needed.

THE FACTS

Explanatory terms

  Deep vein thrombisis (DVT)— development of a clot (thrombus) in the leg

  Pulmonary embolism (PE) —when clot in the leg breaks off and travels round the circulation through the right side of the heart to block the pulmonary arteries. Large ones can be fatal. Small ones can cause chest pain and breathlessness.

  Venous thromboelmbolism (VTE) —a term that encompasses deep vein thrombosis and pulmonary embolism.

  Post-phlebitic syndrome—chronic venous insufficiency after deep vein thrombosis characaterised by swelling, pain, dermatitis, cellulites, varicose veins, pigmentation of the skin and eventually chronic ulceration of the lower leg.

IN THE UK VTE CAUSES AROUND 32,000 DEATHS EACH YEAR

  Risk factors for VTE are well defined1—immobility, acute illness, major surgery especially long operations and orthopaedic surgery, malignancy, pregnancy, increasing age and obesity. The risk is increased further where the patient has several risk factors.

  Deep vein thrombosis is common in hospital in-patients, both in medical and surgical patients, for example prior to specific prevention measures being introduced, around 30% of surgical patients developed a DVT. Furthermore the patient often had no signs or symptoms of this serious complication.

  The condition can lead to sudden death due to pulmonary embolism. Pulmonary embolism following deep vein thrombosis is the immediate cause of death in 10% of all patients who die in hospital.

  VTE has a high recurrence rate. The estimated recurrence rate over 10 years is estimated to 30%.2

  Doctors often forget and patients often don't appreciate that deep vein thrombosis can lead to long term health problems due to post-thrombotic limb and venous ulceration. Around 100,000 people in England and Wales are estimated to suffer from venous leg ulcers often arising following a DVT. Various methods are used to promote healing but some ulcers are resistant, resulting in severe distress and often prolonged periods of hospitalisation. The NHS cost of treating venous leg ulcers is as high as £400 million per year.

  There is a huge body of research showing that use of specific treatments to prevent clots (thromboprophylaxis) reduces the frequency of death and post phlebitic syndrome substantially if given at times of high risk such as after surgery or during an in-patient stay.

  Guidelines do exist to provide advice on thromboprophylaxis. The most widely quoted are the Scottish Intercollegiate Guidelines Network (SIGN) 3.

  In hospital medicine we are reaching the stage where the question should not be "Does this patient need thromboprophylaxis", but a clinical assumption should be that all adult patients need thromboprophylaxis unless there are contraindications and so the question should be "Is there any reason for this patient not to receive thromboprophylaxis?"

ARE WE IMPLEMENTING THROMBOPROPHYLAXIS APPROPRIATELY IN THE UK?

  In the UK we should congratulate ourselves on leading the world in prevention of venous thromboembolism in pregnancy. We have good data collection: The Confidential Enquiry into Maternal Deaths4 in the UK has highlighted that venous thromboembolism remains the commonest cause of maternal death. We have many of the international leaders in the field: they produce superb research. The medical community has responded well: the Royal College of Obstetricians has produced a series of guidelines to obstetricians to highlight the risks and preventative measures5, which are followed by the obstetric community.

  However practice in other fields is not so good. Although the risks of deep vein thrombosis are in the order of one in two in orthopaedic surgery, we know that clinical practice is enormously variable. Indeed last year the Department of Health estimated that four out of every 10 orthopaedic patients do not receive any thromboprophylaxis at all6. A recent audit of 2,000 in-patients from around England showed that 35% of surgical patients and 45% of medical patients who are eligible for thromboprophylaxis are not receiving it7.

  A number of factors have been identified to the under use of thromboprophylaxis, including the perception that VTE was not a significant problem or that prophylaxis was ineffective; physicians lack of awareness of guidelines, concerns about possible side-effects and a lack of funding and infrastructure to adhere to recommendations8.

  To highlight the problems, let us imagine that each one of us needs a hip replacement—a standard and common operation in the NHS. We are all going to be cared for by different orthopaedic surgeons. When we are admitted, we will be counselled and asked to consent about the risks of the operation and perhaps blood transfusion. The risks of blood transfusion are small nowadays. The risk of contracting a major infection through a blood transfusion is about one in half a million. Contrast this with the very real risk of VTE, yet few, if any health professionals will counsel the patient about the risks of venous thromboembolism. Surgery has long been recognised as a major risk factor for VTE, and, after hip surgery, clinical (detectable by a doctor) DVT develop in about 8% of cases. However, if one looks at patients with special scans, up to 60% develop a deep vein thrombosis if they do not receive thromboprophylaxis. About 1-2% of these patients will develop pulmonary emboli.

IF NO THROMBOPROPHYLAXIS IS GIVEN DURING HIP REPLACEMENTS OPERATIONS ABOUT 0.4% RESULT IN DEATH, AND WITHIN FIVE YEARS 16% OF PATIENTS WILL HAVE POST PHLEBITIC SYNDROME WITH NEARLY 4% GETTING LEG ULCERS IN THE LONG-TERM

  Now it may be that your surgeon uses thromboprophylaxis and you will receive daily injections of some form of heparin to reduce the risk. But for many patients they receive inadequate prevention. Why is it that we are receiving counselling about Blood Transfusion, when most of us will receive none at all about the most common complication after surgery—deep vein thrombosis? Currently this is considered acceptable practice in the UK.

HOW CAN WE MAXIMISE THE USE OF THROMBOPROPHYLAXIS?

  Recently the French Government has set a target to reduce the incidence of deep vein thrombosis by 15%9.

  In the UK "The prevention of venous thromboembolism in patients undergoing orthopaedic surgery and other high risk surgical procedures" is listed on the eighth NICE work programme6. However at Lifeblood: the thrombosis charity we hold major concerns that the production of guidelines will take several years to develop, that they will be limited to a group of hospitalised patients and more importantly that there will be failure to implement them appropriately.

  We suggest that there needs to be more active intervention from the Department of Health. Perhaps the best model of how the situation can be improved is that of Blood Transfusion. The Dept of Health issued two directives in 1998 (HSC 1998/224) 10 and 2002 (HSC 2002/009) 11 entitled "Better blood transfusion" that set out a number of requirements for improvement in the clinical practice of blood transfusion. These included the appointment of Blood Transfusion specialists within each Trust, and a committee within each trust to supervise the use of blood within the Trust. What has happened? The use of blood is more considered. Practices have improved and changed. Health care professionals have been educated about the use of blood.

  Perhaps such a model might be applicable to thromboprophylaxis. Ideally each trust could be directed to have a committee to oversee the production and adherence to thromboprophylaxis protocols in all area. This would be a win-win situation. For increasing the use of thromboprophylaxis would reduce the mortality and morbidity from VTE at very little cost when compared with both the economic and health costs of the consequences. This is not a difficult project. We understand the disease, we can identify those at risk, we can prevent the problem with simple effective and cheap interventions, but we lack awareness and thereby the will to effect change.

THE POLICY IS CLEAR, INCREASE AWARENESS OF VTE AND REDUCE DEATH AND DISABILITY FROM THE COMMON CONDITION

References:

  1.  Heit J A. Risk factors for venous thromboembolism. Clin Chest Med 2003.

  2.  Heit et al. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med 2000; 160: 761-8.

  3.  Scottish Intercollegiate Guidelines Network (SIGN). www.sign.ac.uk

  4.  The Confidential Enquiry into Maternal and Child Health (CEMACH). www.cemach.org.uk

  5.  Royal College of Obstetricians. www.rcog.org.uk

  6.  Department of Health. Further action to tackle post-code lottery in care [press release]. http://www.dh.gov.uk

  7.  Preliminary pooled data from a national audit. Unpublished data from Sanofi-Aventis

  8.  Kakkar AK et al. Compliance with recommended prophylaxis for venous thromboembolism: improving the use and rate of uptake of clinical practice guidelines. J Thromb Haemost 2004: 2: 221-7.

  9.  French government. Loi de Sante Publique 2004-08- prevention des TVP: une nouvelle priorite (p 79).

10.  Health Service circular HSC 2002/009. Better Blood Transfusion. Date of issue 4 July 2002. http://www.doh.gov.uk/publications/coinh.html

11.  Health Service Circular HSC 1998/224. Better Blood Transfusion.





 
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