Quality of Life and Economic Costs Associated With Postthrombotic Syndrome

Sumesh Kachroo; Dylan Boyd; Brahim K. Bookhart; Joyce LaMori; Jeff R. Schein; David J. Rosenberg; Matthew W. Reynolds

Disclosures

Am J Health Syst Pharm. 2012;69(7):567-572. 

In This Article

Abstract and Introduction

Abstract

Purpose Published evidence on quality-of-life (QOL) outcomes and health care costs in patients with postthrombotic syndrome (PTS), a common and difficult-to-diagnose complication of venous thromboembolism (VTE), is reviewed.
Summary Occurring in as many as 70% of patients with VTE, PTS remains a challenging and costly disorder, partly due to the lack of a standard diagnostic definition and varying classification systems. Searches of Medline and EMBASE identified 12 articles on humanistic and economic outcomes associated with PTS. The results of U.S. and international studies indicate that PTS is a key determinant of long-term QOL among patients with VTE. In one large study, 37% of patients with VTE developed PTS within two years of a diagnosis of deep venous thrombosis (DVT), and 4% developed severe PTS, with the occurrence of PTS linked to clinically relevant declines in measures of physical and mental health. Research indicates that the economic burden of PTS in the United States may be as high as $200 million annually. Recent progress in efforts to develop standard PTS terminology may facilitate the dissemination of clear consensus guidelines to assist in timely PTS detection and optimal care.
Conclusion Appropriate measures to decrease PTS-related burdens may include the prevention of DVT, clear diagnostic criteria for PTS, and an education campaign aimed at increased standardization in the management of DVT. Gaps in the current understanding of the risk factors, diagnostic criteria, preventive strategies, and even treatment modalities for PTS hamper the ability of clinicians to employ measures that could reduce the occurrence of this disorder and the associated morbidity.

Introduction

Venous thromboembolism (VTE) continues to be a major cause of morbidity and mortality in the United States.[1] Even after successful initial treatment, patients with VTE can experience long-lasting effects such as an increased risk for recurrent VTE and other peripheral vascular disorders, as well as medication-related adverse events. Postthrombotic syndrome (PTS), the most common long-term complication of VTE, is a chronic condition that may occur in patients subsequent to the development of deep venous thrombosis (DVT).

PTS is characterized by limb heaviness, swelling, pain, and, in serious cases, skin ulcers.[2] Despite adequate initial treatment, 20–70% of patients who have symptomatic DVT develop PTS, the majority of them within two to three years.[2,3,4,5,6] Risk factors for PTS include proximal DVT, recurrent DVT, female sex, increasing age, high body mass index, thrombophilia, hormone therapy, varicose veins, abdominal surgery, and elevated D-dimer levels.[2,3,5,7]

PTS is relatively common but has been the focus of few studies for a variety of reasons, including the lack of a consensus diagnostic definition of PTS. In addition, prospective studies of PTS require long follow-up periods, making such studies time-consuming and costly.[3,8] Also, there is currently no International Classification of Diseases (ICD) code for PTS, which complicates patient identification and makes economic evaluations and retrospective studies difficult.

A uniform definition for the diagnosis of PTS and the classification of its severity (using the clinical scale of Villalta et al.[9]) was recently proposed for use in clinical studies and is referred to in this review as the PTS score.[10] The proposed definition emerged from discussions of attendees of a symposium convened by the Control of Anticoagulation Subcommittee of the International Society on Thrombosis and Haemostasis during the society's 54th Scientific and Standardization Committee Meeting in 2008. The symposium highlighted clinicians' urgent concerns about the lack of a uniform definition of PTS and the need for ongoing efforts to develop a standard definition of the syndrome.

A uniformly adopted clinical definition of PTS should have good reproducibility, as well as clinical meaningfulness.[8] Moreover, it should allow for the measurement of the severity of PTS. Currently, three clinical scales are used for the diagnosis of PTS;[9,11–13] however, none has undergone a thorough evaluation for reliability, validity, or responsiveness to change. In addition, there have been no studies assessing the use of the three scales in clinical settings for the routine monitoring of patients with DVT. Current efforts to bring about more consistency in the use of PTS terminology in clinical studies may ultimately lead to more accurate estimates of the incidence and prevalence of PTS. Initiatives to develop and disseminate a uniform definition of PTS, as well as an associated ICD code, require immediate attention as a path to earlier and more precise diagnosis of PTS and, consequently, better disease management.

Perhaps largely because there is no clear definition of the disorder, PTS is a somewhat overlooked condition. Physicians should be encouraged to screen all patients with DVT for PTS during follow-up visits.[3,14] There is a need for uniform guidelines on the frequency with which patients who have DVT should be evaluated for PTS. The majority of patients develop PTS within a few years of a diagnosis of DVT (often within two years, some studies indicate); however, studies entailing long follow-up periods have shown that PTS can develop many years later than that.[2–5,15] Therefore, the development of clear guidelines on monitoring and screening for PTS is required. Such guidelines will also help achieve a more uniform approach to patient care. In addition to a significant economic impact in terms of direct and indirect societal costs, PTS may also decrease the quality of life (QOL) of affected patients. However, there is a relative dearth of reports in the literature focusing on the economic and humanistic burdens associated with PTS. The goal of this review is to identify and summarize the published evidence on those burdens.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....