In a recent edition to JAMA Internal Medicine’s “Teachable Moment” series, Srikanth Nagalla, MD, and the co-authors of “Thrombophilia Testing in Provoked Venous Thromboembolism” presented a case in which a 52-year-old woman with hypertension and type-2 diabetes had groin pain after a fall and received anticoagulation therapy and thrombophilia testing—even though evidence recommended against the testing.
“When patients have certain procedures, they may experience deep vein thrombosis or pulmonary embolism, commonly known as a blood clot or VTE,” said Dr. Nagalla, Associate Professor of Internal Medicine and Director of the Hematology/Oncology Fellowship at The University of Texas Southwestern Medical Center. “It should be clear to clinicians whether the clot was provoked by a recent surgery. Thrombophilia testing might matter if a patient has a clot out of the blue, but for most patients, the tests do not matter.”
The authors cite the American Society of Hematology Choosing Wisely recommendation against thrombophilia testing in adult patients with VTE “occurring in the setting of a major transient risk factor in light of the financial burden and potential harms of inappropriate anticoagulation.”
Dr. Nagalla noted the negative repercussions for over-treating patients, which can include additional anxiety, costs and potential false positives or false diagnoses. The treatment for clots—anticoagulation therapy or blood thinners—would normally be prescribed regardless of whether or not thrombophilia testing takes place. However, the length of time a patient is on the medication is only determined by the provoked or unprovoked nature of the clot and not thrombophilia testing.
“Patients who test positive for a thrombophilia might receive unnecessary long-term anticoagulation for a provoked clot when only a three-month treatment course would be sufficient in most instances,” Dr. Nagalla said. “The longer they are on these medications, the increased risk for bleeding. We have to balance the risk of bleeding and clotting with these medications.”
Dr. Nagalla said that Dr. Ravi Sarode, Director of Transfusion Medicine and Hemostasis division at UT Southwestern Medical Center and one of the article’s co-authors, spearheaded the efforts to reduce inappropriate thrombophilia testing at his institution. After the implementation of local guidelines and appropriate screening questions in electronic medical records, inappropriate thrombophilia testing was reduced by 90 percent. Dr. Sarode was recognized by the American Society of Hematology as a Choosing Wisely Champion at the 58th annual meeting in December of 2016 for his work on inappropriate thrombophilia testing.
“Teachable Moments” gave Dr.Nagalla and his colleagues the opportunity to share learnings with clinicians beyond UT Southwestern Medical Center to encourage others to consider what tests and treatments they order.
“We feel that teachable moments are a good way to educate physicians, especially internists and hospitalists, who are dealing with patients like this on a daily basis,” said Dr. Nagalla. “We try to use a commonly encountered patient scenario and illustrate the potential harm from doing the test. Everyone can relate to this because they or a colleague had a patient who had a clot and was likely prescribed an unneeded test.”