Avaliação da tromboprofilaxia em pacientes clínicos hospitalizados: um estudo de coorte

Abstract

Introduction: venous thromboembolism (VTE) is the third most common cardiovascular condition worldwide. About 60% of all VTE events in a community is associated with hospital admission. Thromboprophylaxis programs reduce the incidence of VTE by about 60%. Objective: to evaluate the effectiveness of a hospital thromboprophylaxis program in clinical patients using the Risk Assessment Model (RAM) International Medical Prevention Registry on Venous Thromboembolism (IMPROVE7). Method: this is a prospective cohort study. All adult patients hospitalized in clinical wards of a public hospital were invited to participate. Psychiatric, gynecological, and obstetric patients were hospitalized directly in an intensive care unit (ICU), coronary unit (CU), those hospitalized for less than 48 hours, hospitalized patients for treatment of venous thromboembolic events and indication for anticoagulant use in the first 48 hours of admission. Hospitalized clinical patients were evaluated for thromboembolic risk by applying RAM IMPROVE7, this was collected by both the assistant physician responsible and the research team. The agreement between the variables of RAM IMPROVE7 and risk classification among assistant physicians and researchers was assessed by adjusted Kappa coefficient. Coefficients above 0.61 were defined as good agreement and those above 0.81 as very good. The thromboembolic and death were evaluated at hospital discharge and at 90 days after discharge using a standardized telephone interview. Results: 2,380 patients were included in the period between 08/20/2017 and 02/23/2019, of which 453 (19%) were at high thromboembolic risk according to results of the interview of researchers. The majority of patients (1,717/2,380, 72.1%) were > 60 years of age, 367/2,380 (15.4%) had immobilization or bed confinement for seven or more days; 40/2,380 (1.7%) were admitted to ICU or CU during hospitalization; 264/2,380 (11.1%) had active cancer; 145/2,380 (6.1%) presented paralysis in lower limbs; 17/2,380 (0.7%) reported a history of thrombophilia and 137/2,380 (5.8%) reported previous history of VTE. All adjusted Kappa values were greater than 0.63. The concordance between observers was classified as good to very good for the seven risk factors evaluated in RAM IMPROVE7, with a good classification (0.64, 95% confidence interval [CI], 0.61-0.67) for immobilization, up to very good (0.98, 95% CI 0.97-0.99) for thrombophilia. The Kappa adjusted coefficient for risk classification was 0.63 (95% CI, 0.60-0.67). There were 36/2,380 (1.5%) venous thromboembolic events during follow-up and 302/2,380 (12.7%) deaths. The adjudication of thromboembolic events and the cause of death is underway, in addition to the analysis of risks and benefits of applied thromboprophylaxis. Conclusion: in this study, the incidence of VTE was 1.5%, corroborating with data in the literature. Approximately 20% of hospitalized patients were classified as at high risk for VTE. The concordance between physician assistants and researchers was good to very good for the seven risk factors evaluated in RAM IMPROVE7. The effectiveness of the program is under analysis.