Venous Thromboembolism Prophylaxis among Medical
Patients at US Hospitals
Michael B. Rothberg, MD, MPH
, Maureen Lahti, MBBS, MPH
Penelope S. Pekow, PhD
, and Peter K. Lindenauer, MD MSc
Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA;
Division of General Medicine and Geriatrics, Baystate
Medical Center, Springfield, MA, USA;
Department of Medicine, Tufts University School of Medicine, Boston, MA, USA;
Biostatistics, University of Massachusetts School of Public Health, Amherst, MA, USA.
BACKGROUND: Chemoprophylaxis is recommended for
medical patients at moderate to high risk of venous
thromboembolism (VTE) and is now a requirement of
the Joint Commission on Accreditation of Healthcare
Organizations. To see who receives prophylaxis and how
far hospitals will need to go to meet this requirement,
we examined VTE prophylaxis patterns at US hospitals.
METHODS: We conducted a retrospective cohort study
of adult patients with seven medical diagnoses consid-
ered to carry moderate to high risk of VTE at 376 acute
care facilities in 2004–2005. We excluded patients on
warfarin or with hospital stays of <2 days. VTE
prophylaxis was assessed by billing codes for any
heparin or compression device. We classified patient
risk using a VTE risk prediction model.
RESULTS: Of 351,535 patients included, 36% received
prophylaxis by hospital day 2. Prophylaxis rates were
highest among patients with certain VTE risk factors,
including mechanical ventilation (67%), restraints (57%),
central lines (55%), obesity (46%), and prior VTE (44%).
The median hospital rate was 31% (IQR 19% to 42%); only
3% of hospitals had rates >70%. Compared to patients at
low risk of VTE (<0.05%), patients at high risk (>1.0%) were
more likely to receive prophylaxis (52% vs. 34%, p<0.001).
Hospitals with high rates of prescribing for high-risk
patients also had high rates for low-risk patients.
CONCLUSIONS: VTE prophylaxis rates at US hospitals
are substantially below Joint Commission targets, even
for patients at highest risk of VTE.
KEY WORDS: venous thromboembolism (VTE); hospital mortality;
J Gen Intern Med 25(6):489–94
© Society of General Internal Medicine 2010
Despite decades of research on measures to prevent venous
thromboembolism (VTE), it remains a major source of morbid-
ity and mortality for hospitalized patients, with as many as
16% of high-risk medical patients developing VTE during their
Pharmacologic prophylaxis with subcutane-
ous heparin reduces the risk of VTE by approximately 50%,
and is therefore recommended for specific groups of patients at
high risk of developing VTE. Guidelines produced by the
American College of Chest Physicians (ACCP) recommend
thromboprophylaxis for patients hospitalized for stroke, acute
myocardial infarction, heart failure, respiratory disease, sepsis,
Studies conducted more than a decade ago have shown that
physicians often fail to use this important therapy in a variety of
high-risk settings, including the perioperative period, during
critical illness, and among other high-risk medical patients.
More recently, several large, multinational observational studies
have demonstrated that approximately half of all medical
patients met ACCP criteria for high risk of VTE, and of these,
approximately 60% of US patients received some sort of VTE
However, these studies enrolled fewer than
10,000 US patients at a limited number of hospitals and did
not characterize the variability in prescribing practices among
US hospitals or physicians.
Since then, the Joint Commission on Accreditation of
Healthcare Organizations has recommended that all hospital-
ized medical patients receive prophylaxis against VTE within
2 days of admission or have documentation as to why no VTE
prophylaxis was given.
To better understand who receives VTE
prophylaxis, and to see how far hospitals will need to go to meet
the new Joint Commission requirements, we examined patterns
of use of VTE prophylaxis among a large and representative
sample of hospitalized medical patients in the US.
Setting and Patients
We identified a sample of patients discharged between January
1, 2004 and June 30, 2005 from 376 acute care facilities in the
US that participated in Premier’s Perspective, a database used
to measure quality and resource utilization, which has been
Participating hospitals represent all
regions of the US and are similar in composition to US
hospitals; however, in comparison to information contained
in the American Hospital Association annual survey, Perspec-
Received October 2, 2009
Revised January 29, 2010
Accepted February 4, 2010
Published online March 30, 2010