Coagulation

Venous thromboembolism undertreated and overtreated in Australia


The lack of comprehensive Australian guidelines on venous thromboembolism management is contributing to the undertreatment and overtreatment of patients, a group of doctors say.

A recent survey of haematologists and respiratory physicians found 41% of doctors would treat a first episode of provoked pulmonary embolism with 6-12 months of anticoagulants.

However, existing international guidelines recommend treatment for only three months due to the risk of bleeding, the study published in Internal Medicine said.

Dr Rory Wallace, from the research team based at the Royal Melbourne Hospital, told the limbic there were a number of scenarios where local guidelines would be helpful.

“We felt that information is a bit disparate, for example from the European Society of Cardiology, American College of Chest Physicians or NICE guidelines. A statement of general consensus from Australian institutions might help reduce uncertainty in some scenarios.”

The survey found evidence of undertreatment in the area of thrombolysis for patients with high-risk pulmonary embolism without contraindications to thrombolysis.

Just over two thirds of doctors (68%) said they would recommend thrombolysis – in keeping with major guidelines.

“However, 18% indicated they would rarely or never recommend thrombolysis and 14% indicated they would only recommend thrombolysis sometimes,” the study said.

Haematologists were four times more likely than respiratory physicians not to recommend thrombolysis while doctors in private hospitals were six times more likely not to recommend than their public hospital colleagues.

Dr Wallace said there was also inconsistency around management of intermediate risk pulmonary embolism. A surprising 22% of doctors said patient preference would not influence their decision to use thrombolysis.

“Given the nature of intermediate risk pulmonary embolism, this is an area where there is not a clear risk versus benefit regarding whether to treat and patient opinion is important,” he said.

The study said discrepancies between guidelines on cancer screening for patients with first episode unprovoked pulmonary embolism were also reflected in practice inconsistencies.

“Australian guidelines could unify the approach and may reduce unnecessary screening,” the study said.

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