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.
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.
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.
UK VTE CAUSES AROUND
32,000 DEATHS EACH
Risk factors for VTE are well defined1immobility,
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
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?"
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 replacementa 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.
0.4% RESULT IN
YEARS 16% OF
4% GETTING LEG
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 surgerydeep vein thrombosis?
Currently this is considered acceptable practice in the UK.
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
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.
OF VTE AND
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
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