Coagulation Counseling

Dr. Garrett is manager of the Health Education Center at Mission Hospitals in Asheville, North Carolina.

LMWH Lowers DVT Risk After Arthroscopic Surgery

A recent study of patients undergoingarthroscopic knee surgery showed adecrease in deep vein thrombosis (DVT)in patients who weretreated with prophylacticlow-molecularweightheparin (LMWH)for 7 or 14 days aftersurgery. Investigatorsrandomized 1761 patientswho underwentknee arthroscopy in anItalian clinic to wearfull-length graduated compression stockingsfor 7 days or to receive daily subcutaneousLMWH for 7 or 14 days.

After 3 months, the incidence of theprimary efficacy endpoint—asymptomaticproximal DVT, proximal or distalsymptomatic DVT, or death from anycause—was significantlylower in theLMWH groups (0.9%in both the 7- and14-day groups) thanin the stocking group(3.2%). These primaryendpoint events weremore common inpatients who underwentmeniscectomy than in those whounderwent diagnostic arthroscopicprocedures or surgeries not involvingmeniscus removal.

Acting Surgeon General Issues Call to Action

Acting Surgeon General Steven K.Galson, MD, MPH, has issued a call toaction to reduce the number of casesof deep vein thrombosis (DVT) and pulmonaryembolism (PE) in the UnitedStates. DVT and PE affect an estimated350,000 to 600,000 Americans eachyear. Together, DVT and PE contribute toat least 100,000 deaths each year.

The call to action urges a coordinated,multifaceted plan to reduce the numbersof cases of DVT and PE nationwide.The plan emphasizes the need for:

• Increased awareness about DVT and PE
• Evidence-based practices for DVT
• More research on the causes, prevention, and treatment of DVT

The call to action resulted from aSurgeon General's Workshop on DVTthat was convened in May 2006. Thecomplete document is available at:www.surgeongeneral.gov/library/calls/index.html.

Low-Dose Aspirin Helps Prevent Clots in PV

Polycythemia vera (PV) and essentialthrombocytosis (ET) are chronic disorderswith an increased risk of arterialand venous thrombosis, as well asbleeding.

Based on the estimated individualrisk of thrombotic and bleeding complications,different therapeutic strategiesare available: phlebotomy for PVor platelet apheresis for ET, or drugtherapy (eg, hydroxyurea, anagrelide,interferon alpha) and aspirin to preventplatelet aggregation. Long-term administrationof aspirin is associated withan increased risk of major upper gastrointestinalbleeding and hemorrhagicstroke, however.

The efficacy of low-dose aspirin hasbeen studied in PV, and, given theevidence, it appears that the risk ofbleeding is outweighed by the benefitof a reduction in fatal thromboticevents when compared with placebo.No increased risk of major bleedingwas noted. Therefore, low-dose aspirinis recommended for patients with PVand no contraindications to therapy.No studies on the effects of low-doseaspirin in patients with ET have beenpublished.

CMS Adds PostoperativeDVT/PE to List of "NeverEvents"

The Centers for Medicare & MedicaidServices (CMS) announced that it is takingseveral actions to improve the qualityof care in hospitals and reduce thenumber of preventable medical errorsthat result in serious consequences forthe patient.

Numerous studies have documentedthe detrimental effects on patients andthe increased costs of health care servicesresulting from a patient's preventableinjury or condition acquired due tohospital errors.

These can include "never events"—those events that never should occur—like amputation of the wrong limb ortransfusing patients with the wrongblood type.

CMS is working with the NationalQuality Forum (NQF)—a national organizationacting to promote patient safetyand improve hospital care—on ways toreduce or eliminate 28 Never Eventsidentified by NQF.

Among the newest group of NeverEvents is deep vein thrombosis (DVT)or pulmonary embolism (PE) after totalknee or total hip replacement surgery.The new ruling means that CMS willnot pay facilities for additional costsincurred as a result of the event. CMShas determined that DVT/PE is reasonablypreventable with proper care.

In addition to the final rule, CMS senta letter to state Medicaid directors providinginformation about how states canadopt the same never events practices.The letter specifically encourages statesto adopt the same nonpayment policiesoutlined in the final Medicare rule.

Nearly 20 states already have or areconsidering methods to eliminate paymentfor some never events. The finalrule is effective for discharges afterOctober 1, 2008.