Although research has established that anticoagulation is generally associated with better outcomes in hospitalized COVID-19 patients, how much to administer has continued to be debated throughout the pandemic.
Venous thromboembolism (VTE) has been a leading complication of COVID-19, and from the earliest days of the outbreak, clinicians had to decide between prophylactic- and treatment-dose anticoagulation for VTE.
A recent study from the University of Utah and the University of Michigan researchers points out that it remains unclear how hospitals have managed VTE prevention and the effect of prevention strategies on mortality.
The study team sought to characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19. Also assessed was the association of anticoagulation strategies with in-hospital and 60-day mortality. Their results were published in JAMA Network Open.
The best way to use anticoagulation with COVID-19 inpatients has troubled clinicians from the first novel coronavirus cases, however.
“Early publications of high VTE rates likely influenced clinical practice related to VTE prophylactic- and treatment-dose anticoagulation,” the authors write. “First, there has been a concerted emphasis on VTE prophylaxis for hospitalized patients with COVID-19. Second, many experts have advocated for escalating doses of prophylactic anticoagulation for some patients hospitalized with COVID-19.”
Research suggesting lower mortality rates with anticoagulation made the debates even more critical, according to the report, which adds, “Given these findings, we sought to better understand variation in anticoagulation practices for patients hospitalized with COVID and the relationship of anticoagulation strategies with in-hospital and 60-day mortality.”
The cohort study, which focused on adults hospitalized between March 7, 2020, and June 17, 2020, used a pseudorandom sample from 30 Michigan hospitals participating in a collaborative quality initiative. Researchers analyzed nonadherence to VTE prophylaxis—defined as missing 2 or more days of VTE prophylaxis and receipt of treatment-dose or prophylactic-dose anticoagulants versus no anticoagulation during hospitalization.
Participants were 1,351 patients with COVID-19; their median age was 64 years, slightly more than half were men and about half were Black. The authors advise that only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation.
Results indicate that 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 1,127 patients who ever received anticoagulation, about a third, 34.8%, missed 2 or more days of prophylaxis, according to the report, which notes that missed prophylaxis varied from 11% to 61% across hospitals and dropped over time (aOR, 0.89; 95% CI, 0.82-0.97 per week).
The authors found that 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).
Furthermore, researchers point out, receiving any dose of anticoagulation versus 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), although only the prophylactic dose of anticoagulation appeared to 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).
“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,” researchers conclude. “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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