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. 2021 Jun 1;4(6):e2111788.
doi: 10.1001/jamanetworkopen.2021.11788.

Trends in Venous Thromboembolism Anticoagulation in Patients Hospitalized With COVID-19

Valerie M Vaughn  1   2   3 , Monica Yost  4 , Chelsea Abshire  4 , Scott A Flanders  3 , David Paje  3 , Paul Grant  3 , Scott Kaatz  5 , Tae Kim  6 , Geoffrey D Barnes  7
Affiliations

Trends in Venous Thromboembolism Anticoagulation in Patients Hospitalized With COVID-19

Valerie M Vaughn et al. JAMA Netw Open. .

Abstract

Importance: Venous thromboembolism (VTE) is a common complication of COVID-19. It is not well understood how hospitals have managed VTE prevention and the effect of prevention strategies on mortality.

Objective: To characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19, as well as the association of anticoagulation strategies with in-hospital and 60-day mortality.

Design, setting, and participants: This cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021.

Exposures: Nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants vs no anticoagulation during hospitalization.

Main outcomes and measures: The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting.

Results: Of a total 1351 patients with COVID-19 included (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0% to 29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.61 per week). Of 1127 patients who ever received anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. Missed prophylaxis varied from 11% to 61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35).

Conclusions and relevance: This large, multicenter cohort of patients hospitalized with COVID-19, found evidence of rapid dissemination and implementation of anticoagulation strategies, including use of treatment-dose anticoagulation. As only prophylactic-dose anticoagulation was associated with lower 60-day mortality, prophylactic dosing strategies may be optimal for patients hospitalized with COVID-19.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Vaughn reported receiving speaking fees from Thermo Fisher Scientific. Dr Yost reported receiving salary support from Blue Cross Blue Shield of Michigan for work with the Michigan Value Collaborative. Dr Flanders reported receiving grants from Blue Cross Blue Shield of Michigan outside the submitted work. Dr Kaatz reported receiving grants from Janssen Pharmaceuticals, Bristol Myers Squibb, and Osmosis Research; he reported receiving consulting fees from Janssen Pharmaceuticals, Bristol Myers Squibb, Pfizer, Alexion Pharmaceuticals, and CSL Behring during the conduct of the study, and consulting fees from Norvartis outside the submitted work. Dr Barnes reported receiving consulting fees from Pfizer/Bristol-Myers Squibb, Janssen Pharmaceuticals, AMAG Pharmaceuticals, Acelis Connected Health, and grants from Blue Cross Blue Shield of Michigan during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Hospital Variation in Percentage of Hospitalized Patients With COVID-19 Who Received Anticoagulation
Each bar indicates 1 hospital. Subfigure B includes only patients who received prophylactic- or treatment-dose anticoagulation at some point during their hospital stay.
Figure 2.
Figure 2.. Trends in Patients Hospitalized With COVID-19 Who Received Anticoagulation by Hospitalization Dates
Error bars indicate 95% CIs. After adjusting for ICU status and hospital clustering, the percentage of hospitalized patients with COVID-19 who received anticoagulation but missed 2 or more days of prophylaxis decreased over time (aOR, 0.89; 95% CI, 0.82-0.97 per week; P = .008). Similarly, the percentage of patients who received treatment-dose anticoagulation without imaging increased over time (aOR, 1.43; 95% CI, 1.30-1.59 per week; P < .001). Time starts at week 0 (March 7-14, 2020).
Figure 3.
Figure 3.. Hospitalized Patients With COVID-19 Who Received Treatment Dose Anticoagulation
ICU indicates intensive care unit; VTE, venous thromboembolism.
Figure 4.
Figure 4.. Mortality Over Time by Anticoagulant Exposure
Each patient was weighted by the inverse probability of being in their anticoagulant exposure group. Compared with no anticoagulation, only prophylactic-dose anticoagulation was associated with lower mortality at 60 days (prophylactic dose: aHR, 0.706; 95% CI, 0.514-0.897; treatment dose: aHR, 0.922; 95% CI, 0.631-1.348).
See this image and copyright information in PMC

Comment in

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