Background: Studies have revealed underutilization of direct oral anticoagulants (DOACs) in the treatment of venous thromboembolism (VTE) despite being addressed in guidelines, including those specific to patients with cancer. Evidence identifies complexity of patient profiles as a potential barrier to the uptake of optimal VTE treatment.
Aims: This study aimed to identify barriers, practice gaps, and causalities related to secondary prevention of VTE in patients with a first occurrence, as well prevention, treatment, and management of risks associated with VTE in cancer. Findings on underutilization of DOACs are presented here.
Methods: A mixed-methods study (semi-structured interviews and quantitative survey) was conducted with physicians from 5 specialties in U.S. community practice settings. Qualitative data was thematically analyzed and survey data was analyzed using Chi-squares and Kruskal Wallis H tests.
Results:
Sub-optimal knowledge of: |
Profession/specialty groups | Participants with sub-optimal knowledge (of total n=241) | Significance (differences between profession/specialty groups)* | ||||
Primary care physicians | Hematologists-oncologists | Community oncologists | Emergency department physicians | VTE specialists (e.g., hematologists, cardiologists, pulmonologists, vascular medicine specialists) | |||
Latest randomized control trials on VTE treatments | 75% (39) |
48% (23) |
66% (29) |
90% (43) |
49% (24) |
65.6% (158) |
p˂.000 |
Guidelines specific to acute treatment for VTE patients | 46% (24) |
40% (19) |
34% (15) |
54% (26) |
27% (35) |
40.4% (97) |
p=.067 |
Recently FDA-approved treatments for VTE | 52% (27) |
40% (19) |
48% (21) |
60% (29) |
40.8% (20) |
48.1% (116) |
p=.226 |
*Chi-square
Profession/specialty groups | Deciding which type of VTE treatment to use according to specific patient profile | Using DOACs with cancer patients |
Primary care physicians | 71.9 (21.1) |
63.3 (24.0) |
Hematologists-oncologists | 73.4 (19.0) |
75.1 (20.2) |
Community oncologists | 67.4 (22.6) |
70.2 (21.5) |
Emergency department physicians | 60.3 (21.8) |
57.4 (22.4) |
VTE specialists (e.g., hematologists, cardiologists, pulmonologists, vascular medicine specialists) | 73.5 (14.7) |
67.7 (22.4) |
Total | 69.4 (20.6) |
66.6 (23.0) |
Asymptotic Significance (differences between profession/ specialty groups)* | p=.006 | p =.002 |
Representative quote: | “With cancer patients often times their comorbidities make decision-making more challenging. They may have metastatic disease that puts them at high risk for bleeding or, if they do bleed, at high risk for morbidity related to a bleed, particularly if they have intracranial metastases or spinal metastases. […] Some of these patients are very advanced, and by the time they’re diagnosed with VTE it’s pretty much the end of the road. So, discussions about what their goals of care are and end-of-life decision-making—we’re not always equipped to do that very well.” – ED Physician |
“NOACs, those new anticoagulants, are still not approved in the cancer treatment patients, so technically we still need to use Coumadin if you want to be going by the book. […] so it’s a challenge, because Coumadin is an old drug and it’s hard to monitor. Because of their cancer, a patient may have problems with their monitoring parameters, which could be falsely elevated or decreased.” – Community Oncologist |
* Kruskal Wallis H
A total of 262 healthcare providers (HCPs) participated in the study, 21 completed interviews and 241 completed surveys. Findings showed a conservative approach to treatment (avoiding DOACs), driven by lack of knowledge and perceived uncertainty of optimal management from guidelines among non-VTE specialists. Qualitative data clarified low knowledge and confidence levels, revealing HCPs’ underlying doubts regarding: DOACs safety, clarity of antithrombotic guidelines, and applicability to cancer. HCPs lacked confidence using patient profile information to guide treatment decisions. Emergency Department (ED) physicians, community oncologists, and primary care providers lacked knowledge about new treatments compared with professionals specialized in VTE and weighed risks of complication heavily. HCPs’ conservative approach regarding DOACs was prevalent when caring for patients with comorbidities or in ED settings.
Conclusions: This study demonstrates the need for education supporting HCPs’ decision-making using DOACs for treating VTE in cancer patients and in acute settings. While HCPs generally understand the benefits of DOACs, they lack confidence in guidelines and can overweight the risks of complication in more constrained and potentially riskier scenarios.
To cite this abstract in AMA style:
Spyropoulos A, Lazure P, Kaatz S, Khorana A, Zahabi S, McCrae K, Pollack C, Péloquin S. VTE Treatment Planning: A Mixed-method Analysis of Clinical Challenges, Knowledge, and Confidence Gaps in Selecting Evidence-based Treatment [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/vte-treatment-planning-a-mixed-method-analysis-of-clinical-challenges-knowledge-and-confidence-gaps-in-selecting-evidence-based-treatment/. Accessed March 22, 2024.« Back to ISTH 2021 Congress
ISTH Congress Abstracts - https://abstracts.isth.org/abstract/vte-treatment-planning-a-mixed-method-analysis-of-clinical-challenges-knowledge-and-confidence-gaps-in-selecting-evidence-based-treatment/