Medications to prevent clots not reaching some patients

June 14, 2013

Researchers at Johns Hopkins report that hospitalized patients do not receive more than one in 10 doses of doctor-ordered blood thinners prescribed to prevent potentially lethal or disabling blood clots, a decision they say may be fueled by misguided concern by patients and their caregivers.

Calling the rate of missed doses "unacceptably high," the researchers add that hospitalized patients are at a significantly greater risk of developing venous , or VTE, and that preventive blood thinners can prevent it a majority of the time.

"There appeared to be a lack of understanding about the risks and benefits of blood thinners among patients and , even though the research is clear that blood thinners are very effective at preventing blood clots," says Kenneth M. Shermock, Pharm.D., Ph.D., the director of the Center for Medication Quality and Outcomes at The Johns Hopkins Hospital, and leader of the study published in the journal PLOS ONE. "Blood clots and their resulting effects are the most common cause of avoidable death for hospitalized patients and we've got a medication that can prevent most of these events. But too many patients are not benefitting."

Shermock and his colleagues say their study found that 12 percent of ordered doses were not administered to patients, with the most commonly documented reason being patient or family-member refusal (59 percent). Patients were sometimes off the floor getting tests or in surgery when the doses are scheduled to be given.

Other research done by Shermock suggests that in some cases nursing staff may have implied to patients that blood thinners are optional. Shermock says it is important to understand the reasons behind this finding and provide more emphasizing the proven benefits of blood thinners for hospitalized patients.

For the PLOS ONE study, Shermock and his colleagues analyzed more than 103,000 VTE prophylaxis doses of unfractionated or ordered for more than 10,500 patients at The Johns Hopkins Hospital between Dec. 1, 2007 and June 30, 2008. Patients from 29 floors were included in the analysis: 11 medicine floors, nine surgery floors, four neurology floors and five intensive care units. They found that while 12 percent of the time ordered doses of blood thinner were not given to the patients, some floors of the hospital had much lower compliance rates.

The findings are similar to results previously reported from a Harvard study, but on a much larger scale. At Harvard, in 2012, the researchers went on to provide an individual information session with every patient to explain the value of the blood thinner shots, an intervention that was successful but costly, Shermock says. The value of his larger study, Shermock says, is that a clear pattern of where the problem is at its worst emerged. The worst compliance rates were found on medicine floors, most notably two of them where some 25 to 30 percent of doses were not administered. Education programs specifically targeted to medicine floors, he says, could yield good results at a fraction of the expense.

Shermock says that, overall, a majority of patients get most of their prescribed doses, which are given at eight-, 12- or 24-hour intervals. Nearly 60 percent of patients received all of their ordered doses. Roughly 20 percent of patients accounted for 80 percent of missed doses, with 20 percent of patients missing at least a quarter of their doses and 10 percent missing more than half of their doses, he says.

Focusing specifically on those patients who have missed doses could make a big impact, he says. The electronic record could be of help with that, showing in real time which patients have refused their medication and thus lead to the staging of an immediate intervention. "We want to be able to get to these patients before there is an adverse event," he says.

In addition to gaining unique insight on the nature of the problem, the Johns Hopkins team appears to be out in front in terms of solutions. Since learning about the data from the study, the Johns Hopkins multidisciplinary Venous Thromboembolism Prevention Collaborative has conducted studies looking at provider and patient factors associated with non-administered doses of VTE prophylaxis. The committee has also learned from nurses, for example, that some patients refused prophylaxis because of the pain and bruising associated with the shots, so a pilot program has been started to test a new method of injection that is less painful.

Meanwhile, a research team led by Elliott R. Haut, M.D., intends to continue this new line of research thanks to a three-year $1.5 million contract from the Patient-Centered Outcomes Research Institute (PCORI), an independent, nonprofit organization authorized by Congress to fund research that will provide patients, their and clinicians with the evidence-based information needed to make better-informed health care decisions. The contract, entitled "Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology," will allow the group to more effectively target and intervene in instances where blood thinners are not being provided, and work with patients, nurses and other members of the health care team to come up with better ways to provide effective VTE prophylaxis.

Michael B. Streiff, M.D., the study's senior author and an associate professor of medicine and pathology in the Division of Hematology, says there remains some discussion about whether all patients on medical floors need prophylactic blood thinners, because some may be at very low risk of developing . That being said, Streiff points out that we do not yet have a well-validated tool to identify which patients do not need prophylaxis.

"The nurses may be exactly right that some of the don't need ," he says, "but more research is needed."

Explore further: Temporary blood clot filters may do more harm than good for bariatric surgery patients

Related Stories

Temporary blood clot filters may do more harm than good for bariatric surgery patients

May 29, 2013
The temporary placement of umbrella-like, metal mesh filters in abdominal veins to stop potentially lethal blood clots from traveling to the lungs during and after weight loss surgery may actually increase the risk of death ...

Surgical-site infections may increase risk of deadly blood clots after colorectal surgery

January 16, 2013
Despite receiving blood thinners and other clot prevention treatment, some patients still develop potentially lethal blood clots in the first month after their operations anyway, especially if they developed a surgical-site ...

Preventing deadly blood clots: Study finds computerized checklist better at finding best preventive strategy

October 15, 2012
A computerized checklist system designed to help physicians identify and use the best methods of preventing potentially deadly blood clots in hospitalized trauma patients dramatically reduced the number of these dangerous ...

ACP recommends new approach to prevent venous thromboembolism in hospitalized patients

October 31, 2011
In a new clinical practice guideline published today in Annals of Internal Medicine, the American College of Physicians (ACP) recommends that doctors assess the risk of thromboembolism and bleeding in patients hospitalized ...

Blood thinners may boost survival for prostate cancer patients

February 21, 2013
(HealthDay)—Men with advanced prostate cancer might live longer when they are taking blood-thinning medication, a small study suggests.

Should you stop blood thinners before surgery? AAN guideline provides direction

May 27, 2013
A new guideline from the American Academy of Neurology will help people who take blood thinners decide whether or not to take them during surgery or other medical procedures. The guideline is published in the May 28, 2013, ...

Recommended for you

Study suggests ending opioid epidemic will take years

July 20, 2017
The question of how to stem the nation's opioid epidemic now has a major detailed response. A new study chaired by University of Virginia School of Law Professor Richard Bonnie provides extensive recommendations for curbing ...

Team-based model reduces prescription opioid use among patients with chronic pain by 40 percent

July 17, 2017
A new, team-based, primary care model is decreasing prescription opioid use among patients with chronic pain by 40 percent, according to a new study out of Boston Medical Center's Grayken Center for Addiction Medicine, which ...

Private clinics' peddling of unproven stem cell treatments is unsafe and unethical

July 7, 2017
Stem cell science is an area of medical research that continues to offer great promise. But as this week's paper in Science Translational Medicine highlights, a growing number of clinics around the globe, including in Australia, ...

Popular heartburn drugs linked to higher death risk

July 4, 2017
Popular heartburn drugs called proton pump inhibitors (PPIs) have been linked to a variety of health problems, including serious kidney damage, bone fractures and dementia. Now, a new study from Washington University School ...

Most reproductive-age women using opioids also use another substance

June 30, 2017
The majority of reproductive-age and pregnant women who use opioids for non-medical purposes also use at least one other substance, ranging from nicotine or alcohol to cocaine, according to a University of Pittsburgh Graduate ...

At-risk chronic pain patients taper opioids successfully with psychological tools

June 28, 2017
Psychological support and new coping skills are helping patients at high risk of developing chronic pain and long-term, high-dose opioid use taper their opioids and rebuild their lives with activities that are meaningful ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.