VTE: A Major Public Health Problem Comes To The Fore

Main Category: Blood / Hematology
Article Date: 04 Nov 2009 - 7:00 PST

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Have hematologists failed to adequately recognize and promote blood disorders as a public health issue? This is a question to ponder as we witness a recent convergence of professional and lay organizations and government agencies collectively focusing their attention on the problem of venous thromboembolism (VTE). This topic was thrust into the limelight by the Surgeon General's Call to Action to Prevent Deep-Vein Thrombosis and Pulmonary Embolism in September 2008. Although the attention paid to this milestone event in the national media was partly sidelined by the severe economic downturn and the Presidential campaign, it does not diminish the fact that such calls to action are relatively uncommon and bring to attention the need to address common and avoidable health threats, such as cigarette smoking or obesity. The genesis of the Call to Action was a May 2006 workshop organized by the Surgeon General, in which several professional societies and patient advocacy groups were represented under the umbrella of the Venous Disease Coalition (VDC, http://www.venousdiseasecoalition.org). Currently, ASH is represented on the VDC Executive Committee by Dr. Jeffrey Weitz, from McMaster University.

Why would VTE prevention merit a Call to Action? The answer lies in the rather staggering, but still imprecise, statistics about the epidemiology of VTE. Pulmonary embolism is now believed to be the foremost preventable cause of in-hospital mortality, as well as the leading cause of maternal mortality in the United States. The incidence of VTE has been variably estimated at anywhere between 200,000 and 900,000 cases per year in this country, accounting for 60,000 to 300,000 deaths.1 To put this in perspective, a conservative estimate of 100,000 deaths annually would be slightly greater than the number due to AIDS, breast cancer, and road traffic accidents combined.2 Of concern is the fact that an estimated 60 percent of cases of VTE are the result of a recent hospitalization, and that one-half to one-third of these subjects did not receive any form of VTE prophylaxis during their inpatient stay. It is a common misconception that the vast majority of these patients were recently discharged from surgical or trauma services, whereas in reality, about one-half had been hospitalized on medical inpatient services. Thus, a tremendous opportunity for the widespread prevention of inpatient mortality on all hospital services - is being lost by the failure to administer VTE prophylaxis.

Fortunately, with a convincing case now made that this is a public health problem of substantial magnitude, several moves are afoot to address the issue. One of the Centers for Disease Control and Prevention (CDC) in Atlanta is the National Center for Birth Defects and Developmental Disabilities, which houses the Division of Blood Disorders (DBD). In August 2008, the CDC/DBD invited ASH to convene a stakeholders' meeting to discuss the need for and potential mechanisms to execute a surveillance mechanism for VTE in the United States. The proceedings of this meeting were nicely summarized by a group led by Gary Raskob, MD, a member of ASH, and will soon be published in the widely read, prestigious CDC publication, Morbidity and Mortality Weekly Report (MMWR). (Check the ASH Web site for a link to the full article.) The report recommends several approaches that might be used to ensure adequate community surveillance. Selection of the optimal strategy requires additional discussion; this is a formidable challenge, given the heterogeneous modes and sites of presentation of VTE. In addition, a national campaign to increase public awareness of DVT and PE was recommended. Much work is also needed here, as evidenced by a previous assessment of public awareness by the American Public Health Association that revealed an appalling lack of knowledge of the risk factors, signs, and symptoms of DVT and PE.2

Other moves to place VTE on the radar screen of the public health community have included a recent proposal to add VTE prevention as a new objective in the "Healthy People 2020" document that is currently being drafted. Several professional societies, including ASH, have participated in the drafting process. "Healthy People," which falls under the auspices of the U.S. Department of Health and Human Services, is a document listing national objectives for promoting health and preventing disease. "Healthy People 2010" included 28 specific topics, none of which included VTE (or any specific mention of blood disorders, for that matter). Given the importance of this document in determining public health priorities at the federal and state levels, the implications are obvious. A new sub-objective on VTE has been proposed to "increase the proportion of referrals/access to hematology specialists for the management of VTE." If accepted, this document may have direct implications for practicing hematologists.

Finally, in partnership with ASH, the NIH, and the Health Resources and Services Administration (HRSA), CDC/DBD will host an inaugural National Conference on Blood Disorders in Public Health in Atlanta in March 2010. The stated purpose of this conference is "to serve as the catalyst for developing a nationally recognized public health framework for promoting the health of and improving outcomes among people at risk for or affected by a non-malignant blood disorder." The anticipated meeting of the minds and sharing of expertise between hematologists, researchers, and public health professionals should provide a novel perspective on the importance of disorders that we treat on a daily basis, with VTE front and center among these disorders.

1. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol. 2008;28:370-72.

2. American Public Health Association. Deep-vein thrombosis: Advancing awareness to protect patient lives. http://www.apha.org/programs/partnerships/dvt.htm.

Source
American Society of Hematology