Prophylaxis for and treatment of deep venous thrombosis after stroke: the Post-Stroke Rehabilitation Outcomes Project (PSROP).

Deep venous thrombosis (DVT) is a common and preventable complication after a stroke. Although the treatment of DVT is simple and straightforward, its prevention remains controversial. The Post-Stroke Rehabilitation Outcomes Project (PSROP) database was used to describe the incidence and temporal sequence of DVT and trends in the prevention and treatment of DVT. Of the 1,161 patients in the PSROP database, 383 (32.99%) patients without DVT and 8 (0.69%) with DVT had no documented orders for anticoagulant medications. Sixty-five (5.60%) patients had DVTs during the inpatient rehabilitation facility stay. Of 10 (0.86%) patients with DVTs in the common femoral vein, 4 (40%) were diagnosed within 24 hours of admission. Nine (90%) of these 10 patients were classified as moderate or severe strokes. All patients with common femoral DVT received appropriate therapy. Although much is known about the prevention, diagnosis, and treatment of poststroke DVT, clinicians need to learn and apply treatment protocols to prevent DVTs and allow more quality time for rehabilitation. Key words: cerebrovascular disorders, cerebrovascular accident, rehabilitation, venous thrombosis

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Behind heart disease and cancer, stroke is the third most common cause of death in the Western world and a leading cause of adult-onset disability. (1) Each year, 700,000 new cases of stroke are reported, and approximately 5.4 million stroke survivors live in the United States. Comprising more than half of the neurological admissions to community hospitals, stroke is the second leading cause for admission to inpatient rehabilitation. Stroke is associated with high costs and intensive utilization of rehabilitation resources, (2,3) and it remains a leading cause for placement into nursing homes or extended care facilities. During 2005, the estimated cost of stroke in the United States totaled $56.8 billion. The annual cost of hospital-based rehabilitation in the United States totaled $5.7 billion in 2001. (4,5)

Deep venous thrombosis (DVT) is an important cause of morbidity after stroke and can lead to the sometimes fatal complication of pulmonary embolus (PE). (6) Approximately 5% of hospitalized stroke survivors will have a clinically diagnosed DVT and approximately 2% will have a diagnosed PE. (7) DVT has been reported in up to 50% of patients who undergo doppler ultrasounds or magnetic resonance imaging. (8) DVT may go undiagnosed, because the affected limb may not become edematous. Some stroke survivors who become dyspneic due to aspiration pneumonia, pulmonary infection, or congestive heart failure actually may have associated pulmonary emboli. Often, autopsies after sudden deaths of stroke survivors identify pulmonary emboli as the cause of the death. PE is important enough to be selected as one of the 10 disease-specific performance measures for the primary stroke center accreditation for the Joint Commission on Accreditation of Healthcare Organizations. (9)

Even though the treatment of DVTs after nonhemorrhagic strokes is rather simple and straightforward, (10) the prevention of DVTs and PEs remains controversial. (11-13) In stroke survivors with restricted mobility, prophylactic low-dose subcutaneous heparin or low molecular weight heparins (LMWH) or heparinoids generally is recommended. (14) Stroke survivors who cannot receive anticoagulants should wear intermittent pneumatic compression devices or elastic stockings. However, the effectiveness of low-dose anticoagulation in conjunction with graduated compression stockings and/or pneumatic compression stockings is yet undetermined. Only one study suggests that ambulating at least 50 feet in or out of the parallel bars irrespective of assistive device or orthotic will significantly reduce the risk of DVT or PE. (15)

The Post-Stroke Rehabilitation Outcomes Project (PSROP) database collected information regarding the general use of anticoagulation therapy during the acute rehabilitation stay. The presence of DVT was documented as comorbid conditions. Although one cannot perform a case-control study comparing the prescription of anticoagulation therapy in stroke survivors with and without DVT, some general concepts can be described. First, the incidence of DVT and the temporal sequence with respect to admission to an inpatient rehabilitation facility (IRF) can be described. Second, the number of stroke survivors who did not receive any anticoagulation therapy can be accounted for, and the incidence of DVT in this subpopulation can be delineated. Finally, the specific treatment courses of stroke survivors who were diagnosed with DVT can be described.

Method and Materials

The PSROP utilizes a clinical practice improvement (CPI) methodology because it captures indepth, comprehensive data about patient characteristics (including clinical signs and symptoms), rehabilitation processes of care, and rehabilitation outcomes needed to characterize the process of care and assess the contribution of individual rehabilitation processes to outcomes. An indepth description of the study's methods, including issues of validity and reliability, can be found in a separate manuscript. (16)

The PSROP consisted of a core group of medical directors from each of seven participating IRFs. The core group developed and implemented patient selection criteria, provided expert advice for the development of a data collection instrument, obtained institutional review board approvals at their respective institutions, oversaw the data collection process, and participated in analyses. The core group also included representatives from physical …