Audit of anticoagulant thromboprophylaxis in hospitalized oncology patients.

BACKGROUND: Venous thromboembolism (VTE) is a significant problem in oncology patients. VTE prophylaxis is underutilized in hospitalized medical patients, but there are few data for the appropriateness and frequency of its use in the oncology subgroup. We aimed to document local practice. METHODS: A cross-sectional chart review of all hospitalized patients cared for by the Christchurch Hospital Oncology Service was carried out during two defined 4-week periods. Assessment for indications and contraindications to prophylactic anticoagulation was based on the 2004 American College of Chest Physicians evidence-based consensus guidelines. RESULTS: Of 113 admissions to the oncology service, 38 (33.6%) had indications for prophylactic anticoagulation. However, 23 of these also had contraindications, leaving only 15 (13%) admissions where prophylactic anticoagulation was deemed appropriate. Only one was appropriately given prophylactic anticoagulation. CONCLUSION: Only a minority of hospitalized oncology patients are appropriate for prophylactic anticoagulation. Where it is suitable, however, it is poorly utilized locally. Local promotion of VTE prophylaxis and further study of this subgroup of hospitalized medical patients may improve uptake of this practice and attenuate morbidity from VTE.

Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism.

BACKGROUND: The Geneva and Wells pre-test probability scores are intended to replace empirical assessment of patients with suspected pulmonary embolism (PE). The effect of clinical experience on the inter-rater variability of these scores, and on empirical judgement, is unknown. AIM: To determine whether medical staff appointment grade affects the inter-rater variability of these pre-test probability scores, or empirical assessment, in patients with suspected PE. DESIGN: Questionnaire survey. METHODS: Doctors were grouped by grade (mean number of years since graduation+/-SEM): house officers 0.7+/-0.2, registrars 6.3+/-0.6, consultants 25+/-4 and applied pre-test probability scores to actual case scenarios. RESULTS: The Geneva score was the most consistent method of determining pre-test probability and was unaffected by clinical experience (Geneva kappa=0.73, Wells kappa=0.38, empirical kappa=0.23, p<0.001 ). With empirical judgement, inter-rater variability was inversely proportional to clinical experience (house officers kappa=0.37, registrars kappa=0.24, consultants kappa= 0.16, p<0.05). DISCUSSION: The Geneva score was the least variable method and can be applied by junior or senior doctors. Using empirical judgement, junior doctors were more likely to agree on the pre-test probability of PE than were their more senior colleagues. This may imply that as physicians gain experience, they recognize that the diagnosis of PE can be difficult to assess and are reluctant to exclude it on clinical grounds.