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Why A-level evidence does not make it to clinicians’ A-list: the case of thromboprophylaxis in medical patients
  1. James D Douketis,
  2. Nancy S Lloyd
  1. McMaster University and St Joseph’s Healthcare; Hamilton, Ontario, Canada

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    A woman in her 40s is admitted to hospital for worsening scleroderma that involves the gastrointestinal tract, skin, and lungs. Although she shows some clinical improvement, 7 days into her hospitalisation a "code blue" is called after she is found to be unresponsive. Resuscitation attempts are unsuccessful. The presumed cause of death is acute pulmonary embolism. A review of her health record indicates that she was not receiving an intervention to prevent deep venous thrombosis (DVT). Could DVT prophylaxis have saved this patient’s life?

    Each year, more than 6 people in every 1000 will develop DVT, and 1 will die from pulmonary embolism (PE)1—more deaths than from breast cancer, AIDS, or motor vehicle accidents. Unlike the latter conditions, DVT is relatively easy to prevent and treat, but in far too many cases, measures to prevent DVT and its embolic sequelae are overlooked.

    In contemporary audits of DVT prophylaxis practices, 65–83% of hospitalised medical patients at risk of DVT were not receiving prophylaxis.2 3 What is difficult to reconcile is that such practices occur in the face of strong "A-level" evidence that anticoagulants should be considered in all at-risk medical patients.4 Indeed, …

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