These practices put MDs at risks for missed DVT claims

These practices put MDs at risks for missed DVT claims

The most important short-term risk of deep vein thrombosis (DVT) is the development of pulmonary embolism (PE), notes Suresh Vedantham, MD, professor of radiology and surgery at Mallinckrodt Institute of Radiology and Washington University School of Medicine in St. Louis, MO.

"PE is a leading cause of unexpected in-hospital death," he says. "A significant number of DVT and PE cases are preventable by use of blood-thinning drugs and leg compression devices in patients who are at risk." Here are practices that put physicians at risk legally:

• Failure to administer DVT prophylaxis.

Many major risk factors for DVT are well known. These risk factors include recent surgery, recent trauma with bony fractures, cancer, immobilization from medical illness, pregnancy, and use of hormonal agents such as birth control pills.

"Within the context of a hospital admission, patients with these conditions are at significant risk of developing DVT and/or PE," says Vedantham. Studies show that less than half of patients who are at risk actually receive the preventive measures, however.^1-3 "Failure to administer DVT prophylaxis is common and certainly puts physicians at medicolegal risk," says Vedantham. "Many strategies have been employed to try to get physicians to do a better job of this, but the results have been patchy."

One approach is to make routine assessment of every patient for their risk of DVT/PE a standard procedure upon hospital admission. "Overall, greater awareness of the risk of DVT/PE among physicians would be helpful," says Vedantham.

• Late diagnosis of DVT.

DVT should be considered in any patient with pain, swelling, or cramping in the legs, especially if it is in just one leg, underscores Vedantham. The combination of clinical indicators, blood test, and ultrasound is effective in diagnosing DVT, he says.

"But the key is that the physician needs to think of it in the first place," Vedantham says. "Failure to consider the diagnosis and initiate treatment in a symptomatic patient can be fatal and is another potential medicolegal risk."

• Lack of close follow-up care.

"The quality and rigor of post-discharge care in the U.S. varies widely," says Vedantham. DVT patients put on blood-thinners are often readmitted with recurrent or progressive DVT or PE due to simple failure to take the drugs. This situation occurs due to a combination of poor instructions to patients, problems with accessing the drugs due to insurance barriers, and lack of close follow-up during the initial weeks to ensure that patients are taking the drugs and that their drug levels are appropriate, says Vedantham.

"Also, drug levels fluctuate a lot, so patients' blood can get too 'thin,' making them prone to bleeding," Vedantham says. "The occurrence of recurrent DVT, PE, or a bleeding complication could be attributed to a physician's failure to put in place a suitable monitoring plan."

• Failure to refer patients to a specialist.

About 40% of patients with a DVT will develop a late complication called post-thrombotic syndrome (PTS), which can permanently impair walking, says Vedantham.⁴

"Proper treatment of the DVT with blood thinners probably helps to prevent PTS, but it is not sufficient in many cases," explains Vedantham. He says patients with large blood clots should be referred to an interventional radiology specialist for consideration for more aggressive clot removal procedures to optimally preserve leg function and prevent PTS.

"It is likely that failure to do this will carry medicolegal risk to a physician, since PTS can be a permanent disabling condition," says Vedantham.

References

1. Anderson FA, Jr., Wheeler HB, Goldberg RJ, et al. Physician practices in the prevention of venous thromboembolism. Ann Intern Med 1991; 115(8):591-595.
2. Steier KJ, Singh G, Ullah A, et al. Venous thromboembolism: application and effective¬ness of the American College of Chest Physicians 2001 guidelines for prophylaxis. J Am Osteopath Assoc 2006; 106(7):388-395.
3. Rahim SA, Panju A, Pai M, et al. Venous thromboembolism prophylaxis in medical inpatients: a retrospective chart review. Thromb Res 2003; 111(4-5):215-219.
4. Kahn SR, Shrier I, Julian JA, et al. Determinants of the post-thrombotic syndrome after lower extremity deep venous thrombosis. Ann Intern Med 2008; 149 (10):698-707.