Troy Brown

April 05, 2012

April 5, 2012 (San Diego, California) — Important changes have been made to the updated guideline for antithrombotic therapy and the prevention of thrombosis that make them much easier to use, according to a presentation here at the Hospital Medicine 2012: Society of Hospital Medicine Annual Meeting.

Catherine Curley, MD, assistant professor of medicine at Case Western Reserve University School of Medicine, and a practicing hospitalist at the MetroHealth Medical Center in Cleveland, Ohio, who cowrote the chapter on the prevention of venous thromboembolism (VTE) in orthopedic surgery patients, spoke about how hospitalists can use this guideline in caring for patients at risk for VTE.

Conflicts of Interest Reduced

For the guideline, methodologists without declared conflicts of interest were used as chapter editors. They underwent rigorous conflict-of-interest screening that addressed both intellectual and financial conflicts of interest. "Each chapter editor is actually a methodologist, a person who has experience in the grade method of evaluating data," Dr. Curley explained.

"There's been an increasing emphasis on avoiding conflicts of interest, or at least disclosing them more fully, which I think is a good thing in this area," Daniel Brotman, MD, FHM, associate professor of medicine at Johns Hopkins University School of Medicine and director of the hospitalist program at Johns Hopkins Hospital in Baltimore, Maryland, told Medscape Medical News.

The guideline can help hospitalists care for patients at risk for VTE in a number of ways, said Dr. Curley. In an interview with Medscape Medical News, she explained that "the guideline is important because physicians really rely upon it to help them make complicated decisions about...really complex patients in the hospital. It's a guideline that's updated and published regularly."

Less Text, More Tables

Several format changes make this guideline easier to use. "[One] very visible change is that there's been a real shift in how the guideline is presented. We've moved from a text-based guideline — where you have to comb through the details of the text to understand the purpose or the foundation for the recommendations — to a series of tables."

"There are 'summary of findings' tables, evidence profiles for given agents, and a lot less text. We're relying on more of a tabular-type format for the data. It also uses a grade method for the examination of evidence. This was used to a certain extent in the previous guideline, but is in a much more robust form in this guideline," said Dr. Curley.

Dr. Brotman said that he is pleased with the guideline. "Guidelines like this are incredibly helpful because this is a really complicated area; you have opinions all over the place. I think that the methodologic rigor that they took was exceptional," he said.

"I also really like the fact that the new guideline highlights specifically where they've changed from the old ones.... That was one of the things that used to make us pull our hair out. We'd read something and we'd say: 'Was that the same thing that was in the old guideline and I missed it, or is that new?'"

The fact that it's highlighted where it is new is helpful," said Dr. Brotman.

Patient-Important Outcomes Receive More Attention

The guideline emphasizes patient-important outcomes more than in the past, said Dr. Curley. "There have been some interesting changes made to the document that makes this guideline very interesting. Those changes include a shift in looking at what we consider to be more patient-important outcomes/clinical events, as opposed to, for example, asymptomatic VTE that's been diagnosed just on a venogram," Dr. Curley said.

"I particularly like the emphasis on using clinically important end points rather than radiographic end points that are not clinical for DVT [deep vein thrombosis]," said Dr. Brotman. "Not because I don't think that it's a good surrogate end point, but because I think it's easy to make the assumption that an asymptomatic DVT that's proximal is as dangerous as a real bleed that's clinical.... That is a stretch I've never been comfortable with. I think that paying a little more [attention] to our surgical colleagues who are scared of bleeding is a refreshing slight shift, with the caveat that I don't like aspirin for ortho patients," he said.

Hospitalists Need to Use Guideline

Dr. Curley believes the guideline will be very helpful to hospitalists, but they need to use it. "Practicing clinicians need to know that the guideline is out there, and it's readily available on the Web. A lot of hospitals and their libraries have subscriptions, so often it's just a click away. If your hospital for some reason doesn't [have a subscription], I recommend that you figure out a way to get regular access to the guideline. I use it probably 3 or 4 times a week myself, on areas that I'm not an expert in, to help manage somewhat complicated patients," she explained.

"There are hundreds of people who worked on this guideline, who combed through really complex data, and have tried to come up with a good summary of the best evidence and how should we be treating our patients. The guideline is a great resource for that," said Dr. Curley.

Dr. Curley and Dr. Brotman have disclosed no relevant financial relationships.

Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting: Presented April 2, 2012.

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