Provider preferences for DVT prophylaxis

Background: Patients admitted to medicine wards are typically elderly with multiple co-morbidities, placing them at significant risk for venous thromboembolic (VTE) disease. Standard guidelines to help physicians assess risk and institute prophylaxis do not currently exist for this patient population. Our purpose was to assess how clinicians would rate a patient's risk for VTE and what recommendations they would make for prophylaxis. Methods: Internal medicine residents and staff at a tertiary care medical center were asked to identify risk factors, evaluate VTE risk, and recommend a method of prophylaxis for patients described in eight clinical vignettes created by the authors. Each vignette was designed to represent a patient at a specific level of risk. Results: 35 physicians returned the survey. Responders were able to identify some risk factors and weigh them appropriately when assigning an overall risk level. There was good agreement on risk level among responders (k = 0.62) and moderate agreement comparing responders with our pre-defined gold standard (GS) (k = 0.42). Compared to the GS they underestimated the level of risk almost 50% of the time. The risk level they assigned affected the type of prophylaxis recommended, with fewer low risk patients receiving any type of heparin and more high risk patients receiving low-molecular weight heparin (LMWH). Conclusions: Although internal medicine physicians are able to identify some risk factors for in-hospital VTE, they consistently underestimate the overall risk, leading to less aggressive preventative measures. Continuing education is essential to combating this preventable inpatient complication.