The present study screened 705 patients from 40 sites across Lebanon and Jordan. Of them, 704 patients (400 from Jordan and 304 from Lebanon) (99.9%) were eligible for final analysis and one patient (0.1%) was excluded as the weight was above 100 kg. Regarding the demographic characteristics of the included patients, the patients’ age ranged from 18 to 93 years with a mean age of 54.9 ± 17.5 years. Almost 48% of the patients were males. The mean weight and height of the included patients were 75.7 ± 13.4 kg and 165.9 ± 9.3 cm, respectively. The BMI of the included patients ranged from 16.1 to 44.2 kg/m2 with a mean BMI of 27.5 ± 4.8 kg/m2. In terms of vital signs, the mean SBP and DBP of the included patients were 124.1 ± 15.4 and 73.8 ± 9.7 mmHg, respectively. Sixty percent of the patients had one or more current medical conditions. The most commonly encountered medical condition was hypertension (34.8%), followed by diabetes mellitus (22.6%) and coronary artery disease (10.1%). Two-hundred and forty-six (34.9%) patients were admitted for medical causes only, 449 (63.8%) patients were admitted for surgical causes only, and 9 (1.3%) patients were admitted for both medical and surgical causes. The average hospital stay of the included patients was 5.8 ± 8.4 days. The Demographic and clinical characteristics of the included patients were summarized in Table 1.
Table 1
Demographic and clinical characteristics of the participants at baseline
Variables
|
Patients (N = 704)
|
Age in years, mean (SD)
|
54.96 (17.5)
|
Male, No. (%)
|
340 (48.3%)
|
Weight in kg, mean (SD)
|
75.72 (13.4)
|
Height in cm, mean (SD
|
165.96 (9.3)
|
BMI in kg/m2, mean (SD)
|
27.47 (4.8)
|
Systolic blood pressure in mmHg, mean (SD)
|
124.1 (15.4)
|
Diastolic blood pressure in mmHg, mean (SD)
|
73.75 (9.7)
|
Pulse rate in beat/min, mean (SD)
|
81.38 (12.5)
|
Temperature in C, mean (SD)
|
36.87 (0.46)
|
Hypertension, No. (%)
|
245 (34.8)
|
Diabetes, No. (%)
|
159 (22.6)
|
History of other chronic illness, No. (%) *
|
503 (71.4)
|
Cause of admission, No. (%)
- Medical Causes
- Surgical Causes
- Medical and Surgical Causes
|
246 (34.94%)
449 (63.78%)
9 (1.28%)
|
Type of Surgery, No. (%)
- Open
- Laparoscopic
|
327 (46.45%)
131 (18.61%)
|
Hospital Stay in days, mean (SD)
|
5.83 (8.4)
|
Risk factors for VTE, No. (%)
- Surgical risk
- Medical risk
- Medical and surgical risk
|
391 (55.5%)
221 (31.4%)
4 (0.6%)
|
Surgical risk factors for VTE, No. (%)
- Obesity
- Age > 60 years old
- Laparoscopic Surgery (> 45 min)
- Other factors*
|
237 (33.7)
117 (16.7%)
59 (8.38)
523 (74.3)
|
Degree of surgical risk factors for VTE, No. (%)
- Low
- Moderate
- High
- Highest
|
162 (23.1)
109 (15.48)
86 (12.22)
38 (5.4)
|
Medical risk factors for VTE, No. (%)
- Elderly Age (≥ 70 Years)
- Reduced Mobility (At Least 72 h)
- Obesity
- Other factors
|
94 (13.35)
93 (13.2)
86 (12.22)
181 (25.7%)
|
Risk factors associated with increased bleeding, No. (%)
|
60 (8.5)
|
Risk factors associated with Mechanical Prophylaxis
|
25 (3.6%)
|
*Patient may have more than one chronic condition
VTE; venous thromboembolism, SD; standard deviation
|
Six hundred and sixteen patients (87.5%) had one or more risk factors for VTE which were either surgical (55.5%), medical (31.4%), or surgical and medical risk factors (0.6%). Sixty patients (8.5%) had risk factors associated with increased bleeding such as active bleeding (1.1%) and low platelet count. In addition, 25 (3.5%) patients had risk factors associated with mechanical prophylaxis which were severe peripheral arterial disease (0.4%), congestive heart failure (2.8%), and acute superficial/deep vein thrombosis (0.3%).
Among the 704 patients who were eligible for the final analysis, 415 (58.9%) patients received prophylaxis treatment in form of pharmacological anticoagulant prophylaxis (n = 371, 52.7%), mechanical prophylaxis (n = 13, 1.8%), and pharmacological plus mechanical prophylaxis (n = 31, 4.4%). LMWH was the most commonly used anticoagulant for VTE prophylaxis (n = 366); however, the unfractionated heparin was administrated in 56 patients only as seen in Table 2. In Lebanon as well as Jordan, LMWH was the most commonly used anticoagulant for VTE prophylaxis (N = 192, 48%) and (N = 174, 57.2%), respectively (Table 3).
Table 2
VTE prophylaxis/treatment of the included patients
Variables
|
Patients (N = 704)
|
No. of patients received prophylaxis, No. (%)
- Pharmacological anticoagulant prophylaxis
- Mechanical prophylaxis
- Pharmacological and Mechanical prophylaxis
|
415 (58.9)
371 (52.7)
13 (1.8)
31 (4.4)
|
Types of anticoagulant, No. (%)
- LMWH
- Unfractionated Heparin
|
366 (51.9)
56 (7.9)
|
Timing of anticoagulants for surgical patients, No. (%)
- Preoperatively
- Postoperatively
- Preoperatively/ Postoperatively
|
138 (59.23)
94 (40.34)
1 (0.43)
|
No. of patients continued prophylaxis after discharge, No. (%)
|
128 (30.84)
|
Duration of LMWH after discharge, mean (SD)
|
17.58 (80.9)
|
Duration of Warfarin after discharge, mean (SD)
|
28 (16.2)
|
Concomitant treatment No. (%)
|
460 (65.34)
|
LMWH; low molecular weight heparin, SD; standard deviation
|
Table 3
VTE prophylaxis differences according to the included countries
Variables, No (%)
|
Jordan
(N = 400)
|
Lebanon
(N = 304)
|
LMWH
|
192 (48.0%)
|
174 (57.2%)
|
Unfractionated Heparin
|
30 (7.5%)
|
28 (9.2%)
|
Other Anticoagulants
|
3 (0.8%)
|
1 (0.3%)
|
Mechanical Prophylaxis
|
12 (3.0%)
|
32 (10.5%)
|
LMWH; low molecular weight heparin
|
Among surgical patients who received anticoagulants (N = 233), 59.2% of them received the drug preoperatively and 40.3% received it postoperatively. Only 6.3% of the patients received mechanical prophylaxis in the form of graduated compression stockings or intermittent pneumatic compression. Almost 31% of the patients continued anticoagulants treatment after discharge in the form of LMWH (85.9%), aspirin (10.2%), warfarin (3.1%), and Fondaparinux (0.8%).
Among the total 704 eligible patients, 415 (58.9%) patients received VTE prophylaxis, while 289 (41.1%) did not received prophylaxis. For those who received VTE prophylactic treatment, 216 (52%, 95% CI [47.1% − 56.9%) received appropriate prophylactic agents according to ACCP guideline. For those who were not treated with prophylactic agents, 212 (73.4%, 95% CI [67.9% – 78.4%) were actually eligible for VTE prophylaxis according to ACCP guideline as presented in Table 4.
Table 4
Appropriate VTE prophylaxis according to ACCP guidelines
Variables, No (%)
|
Eligible for prophylaxis*
|
Not Eligible for prophylaxis*
|
Total
|
Received prophylaxis
|
216 (30.68%)
|
199 (28.27%)
|
415 (58.95%)
|
Not received prophylaxis
|
212 (30.11%)
|
77 (10.94%)
|
289 (41.05%)
|
Total
|
428 (60.79%)
|
276 (39.21%)
|
704 (100%)
|
* According to ACCP guidelines
|
About 60.9% (95% CI 51.9–69.4%) of the patients (n = 78) received VTE prophylaxis out of the medical patients who were eligible for prophylaxis according to ACCP 2016 guideline (n = 128). While in surgical patients, only 45.1% (95% CI 39.3% − 51%) of the patients (n = 133) received VTE prophylaxis out of those who were eligible for prophylaxis (n = 295), Fig. 1. All patients with combined medical and surgical conditions received appropriate prophylaxis.
Regarding the orthopedic surgery, most of the patients received appropriate VTE prophylaxis according to ACCP 2016 guideline. While in non-orthopedic surgery, the number of patients who received appropriate VTE prophylaxis (N = 170) was lower than the number of patients who were eligible for prophylaxis (N = 227) as seen in Fig. 2.
The supplementary file no.2 shows the distribution of appropriate VTE prophylaxis according to doctors’ specialty and the type of surgery.
Overall, the rate of compliance to ACCP guidelines was higher in private hospitals than in public hospitals (85% versus 57.8%, respectively). The rate of compliance to ACCP guidelines was higher among oncologists (73.3%) and general family specialists (72%) than other specialized doctors. The rate of compliance was higher among cases of orthopedic surgeries (100%) and oncological surgeries (79%) than other types of surgery as presented in Table 5.
Table 5
Rates of Compliance to ACCP guidelines
Variables, No (%)
|
Compliant to ACCP guidelines
|
Not Compliant to ACCP guidelines
|
Total
|
Type of hospital,
- Private Hospital
- Public Hospital
|
125 (85.03)
168 (57.8)
|
22 (14.97)
22 (11.58)
|
147
190
|
Risk Assessment Method implementation
|
170 (37.86)
|
279 (62.14)
|
449
|
Age of patients
- ≥ 40 years old
- < 40 years old
|
262 (47.4)
31 (20.5%)
|
291 (52.6)
120 (79.5%)
|
553
151
|
Physician Speciality
- Pneumology
- Cardiology
- Internal Medicine
- Oncology
- Infectious Disease
- General/Family Medicine
- Orthopaedics Surgery
- Vascular Surgery
- General Surgery
- Other Surgery
|
33 (47.14)
32 (40.51)
37 (39.78)
11 (73.33)
6 (26.09)
18 (72.0)
53 (42.74)
24 (60.0)
84 (38.53)
26 (34.67)
|
37 (52.86)
47 (59.49)
56 (60.22)
4 (26.67)
17 (73.91)
7 (28.0)
71 (57.26)
16 (40.0)
134 (61.47)
49 (65.33)
|
70
79
93
15
23
25
124
40
218
75
|
Type of surgery
- Hip replacement
- Knee replacement
- Hip fracture
- Curative arthroscopy
- Other Ortho trauma
- Colon /small bowel
- Rectosigmoid
- Gastric
- Hepatobiliary
- Vascular
- Thoracic
- Oncologic
- Others
|
16 (100.00%
19 (100.00%
21 (100.00%
0 (0.00%
1 (3.03%
17 (51.52%
7 (63.64%
6 (31.58%
30 (45.45%
0 (0.00%
4 (28.57%
15 (78.95%
60 (28.57%
|
0
0
0
6 (100)
32 (96.97)
16 (48.48)
4 (36.36)
13 (68.42)
36 (54.55)
1 (100)
10 (71.43)
4 (21.05)
150 (71.43)
|
16
19
21
6
33
33
11
19
66
1
14
19
210
|
ACCP; American College of Chest Physicians
|
The multivariate logistic regression analysis showed that only age was a significant predictor of appropriate VTE prophylaxis in the present study (OR 1.05, 95% CI [1.04–1.07], P < 0.001) (Table 6).
Table 6
Multivariate logistic regression analysis to identify the significant Predictor Variables for appropriate prophylaxis.
|
OR
|
95% C.I. for OR
|
P value
|
Lower
|
Upper
|
Age
|
1.05
|
1.042
|
1.071
|
< 0.001*
|
Gender
|
1.11
|
0.764
|
1.627
|
0.573
|
BMI
|
0.99
|
0.954
|
1.033
|
0.719
|
SBP
|
0.98
|
0.974
|
1.004
|
0.145
|
DBP
|
1.00
|
0.983
|
1.031
|
0.567
|
HR
|
1.01
|
0.994
|
1.027
|
0.226
|
Temperature
|
1.13
|
0.733
|
1.768
|
0.564
|
Hospital Stay
|
1.02
|
0.996
|
1.047
|
0.094
|
Included hospitals
|
0.97
|
0.918
|
1.041
|
0.480
|
Type of hospital
|
1.48
|
0.872
|
2.505
|
0.147
|
Site of hospitals
|
1.23
|
0.986
|
1.558
|
0.066
|
Medical Reasons
|
2.95
|
0.536
|
16.281
|
0.213
|
Surgical Reasons
|
0.68
|
0.125
|
3.771
|
0.664
|
*Patients’ age is the only significant predictor for appropriate prophylaxis
OR; odds ratio, CI; confidence interval
|