PURPOSE: Despite the existence of evidence-based guidelines for the management of VTE, significant variability in clinical practice exists. We sought to quantify the differences in practice patterns and to determine the factors that lead to them.
METHODS: A survey was conducted amongst general internists and medicine subspecialists. The questionnaire was developed online (www.surveymonkey.com) and disseminated to physicians at six military medical centers. All responses were recorded, and subgroups analyses were performed based on provider subspecialty, years in practice, and numbers of VTEs treated per year.
RESULTS: There were a total of 83 respondents (30 internal medicine, 31 pulmonary/critical care, 13 hematology/oncology, 8 other subspecialists, and 1 family medicine). Respondents had been in practice a mean duration of 9.35 years. On average, respondents treated 14.4 VTEs per year. Seventy-seven percent used LMWH as the therapeutic agent of choice for initial submassive PE in patients with normal renal function. However, clinicians with a greater number of years in practice (mean 13.1 years) favored UFH over LMWH (mean 8.0 years) (p=0.03). Substantial variability existed regarding the duration of anticoagulation. Following a first episode of unprovoked DVT, the duration of anticoagulation was reported as 6 weeks (3.6% of respondents), 3 months (27.7%), 6 months (47.0%), 12 months (9.6%) and other/it depends (12.0%). Reported durations of anticoagulation were similar for unprovoked PE - 3 months (9.6%), 6 months (49.4%), 12 months (27.7%), and other/it depends (13.3%). Only 36.1 percent of respondents check d-dimer following discontinuation of anticoagulation. Providers who see more VTEs were more likely to order a d-dimer (19.9 vs. 11.2, p=0.03).
CONCLUSION: Substantial variability exists in the management of VTE, particularly regarding the duration of anticoagulation. Although the benefit of a finite duration of anticoagulation greater than 3 months remains uncertain, many clinicians continue to treat for six months or more.
CLINICAL IMPLICATIONS: Continued research into predictors of recurrence following discontinuation of anticoagulation is needed. Continued education of providers on current evidence for treatment of VTE will optimize care for this condition.
DISCLOSURE: Antonio Garcia, No Financial Disclosure Information; No Product/Research Disclosure Information