Highlights
- •A clinical vignette-based experiment mimicked the setting in which decision-making occurs.
- •774 cases of hematologic cancer, platelets<50,000/µL & anticoagulation were addressed.
- •Physicians usually continue anticoagulation with strategies mitigating the bleeding risk.
- •The CHA2DS2-VASc score affected anticoagulation management in atrial fibrillation.
- •The decision process is intricate & compatible with venous thromboembolism guidelines.
Abstract
Background
Thrombocytopenia in cancer patients with an indication for anticoagulation poses a
unique clinical challenge. There are guidelines for the setting of venous thromboembolism
but not atrial fibrillation (AF). Evidence is lacking and current practice is unclear.
Objective
To identify patient and physician characteristics associated with anticoagulation management
in hematological malignancy and thrombocytopenia.
Methods
A clinical vignette-based experiment was designed. Eleven hematologists were interviewed,
identifying 5 relevant variable categories with 2–5 options each. Thirty hypothetical
vignettes were generated. Each physician received 5 vignettes and selected a management
strategy (hold anticoagulation; no change; transfuse platelets; modify type/dose).
The survey was distributed to hematologists and thrombosis specialists in 3 countries.
Poisson regression models with cluster robust variance estimates were used to calculate
relative risks for using one management option over the other, for each variable in
comparison to a reference variable.
Results
168 physicians answered 774 cases and reported continuing anticoagulation for venous
thromboembolism or AF in 607 (78%) cases, usually with dose reduction or platelet
transfusion support. Overall, management was affected by platelet count, anticoagulation
indication, time since indication, type of hematological disease and treatment, and
prior major bleeding, as well as physician demographics and practice setting. The
CHA2DS2-VASc score and time since AF diagnosis affected anticoagulation management in AF.
Conclusion
This study indicates what the widely accepted management strategies are. These strategies,
and possibly others, should be assessed prospectively to ascertain effectiveness.
The decision process is intricate and compatible with current venous thromboembolism
guidelines.
Keywords
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Article info
Publication history
Published online: March 13, 2020
Accepted:
March 5,
2020
Received in revised form:
March 3,
2020
Received:
January 19,
2020
Identification
Copyright
© 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
