Journal of Thrombosis and Thrombolysis

, Volume 46, Issue 1, pp 113–119 | Cite as

Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study

  • Z. Tazi Mezalek
  • C. Nejjari
  • L. Essadouni
  • M. Samkaoui
  • K. Serraj
  • W. Ammouri
  • N. Kanjaa
  • Z. Belkhadir
  • B. Housni
  • M. Awab
  • M. Faroudy
  • W. Bono
  • S. Kabbaj
  • M. Akkaoui
  • M. Barakat
  • R. Rifai
  • H. Charaf
  • A. Aziz
  • Y. Elachhab
  • A. Azzouzi


Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5 years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.


Thromboprophylaxis Venous thrombosis Hospitalized patients Risk assessment 



American College of Chest Physicians


Deep vein thrombosis


Low molecular weight heparin


Pulmonary embolism


Risk assessment model




Venous thromboembolism



Collection of registry data for this study was sponsored by Sanofi Morocco.

Compliance with ethical standards

Conflict of interest

All authors declare no conflicts of interest.


  1. 1.
    Alikhan R, Peters F, Wilmott R et al (2004) Fatal pulmonary embolism in hospitalized patients: a necropsy review. J Clin Pathol 57:1254–1257CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Lindblad B, Sternby NH, Bergqvist D (1991) Incidence of venous thromboembolism verified by necropsy over 30 years. BMJ 302:709–711CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Sandler DA, Martin JF (1989) Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med 82:203–205CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Bouras G, Burns EM, Howell AM et al (2015) Risk of post-discharge venous thromboembolism and associated mortality in general surgery: a population-based cohort study using linked hospital and primary care data in England. PLoS ONE 10:e0145759CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Spencer FA, Lessard D, Emery C et al (2007) Venous thromboembolism in outpatient setting. Arch Intern Med 167:1471–1475CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Dentali F, Douketis JD, Gianni M et al (2007) Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 146:278–288CrossRefPubMedGoogle Scholar
  7. 7.
    Lloyd NS, Douketis JD, Moinuddin I et al (2008) Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis. J Thromb Haemost 6:405–414CrossRefPubMedGoogle Scholar
  8. 8.
    Koch A, Bouges S, Ziegler S et al (1997) Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention: update of previous meta-analyses. Br J Surg 84:750–759CrossRefPubMedGoogle Scholar
  9. 9.
    Lederle FA, Zylla D, MacDonald R et al (2011) Venous thromboembolism prophylaxis in hospitalized medical patients and those with stroke: a background review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 155:602–615CrossRefPubMedGoogle Scholar
  10. 10.
    de Lissovoy G, Subedi P (2002) Economic evaluation of enoxaparin as prophylaxis against venous thromboembolism in seriously ill medical patients: a US perspective. Am J Manag Care 8:1082–1088PubMedGoogle Scholar
  11. 11.
    O’Brien JA, Caro JJ (2002) Direct medical cost of managing deep vein thrombosis according to the occurrence of complications. Pharmacoeconomics 20:603–615CrossRefPubMedGoogle Scholar
  12. 12.
    Shekelle PG, Pronovost PJ, Wachter RM (2013) The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 158:365–368CrossRefPubMedGoogle Scholar
  13. 13.
    Qaseem A, Chou R, Humphrey LL et al (2011) Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 155:625–632CrossRefPubMedGoogle Scholar
  14. 14.
    Amin A, Spyropoulos C, Dobesh P et al (2010) Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start). J Thromb Thrombolysis 29:326–339CrossRefPubMedGoogle Scholar
  15. 15.
    Cohen AT, Tapson VF, Bergmann JF, ENDORSE Investigators (2008) Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 371:387–394CrossRefPubMedGoogle Scholar
  16. 16.
    Geerts WH, Bergqvist D, Pineo GF et al (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence Based Clinical Practice Guidelines. (8th edition). Chest 133:381S–453SCrossRefGoogle Scholar
  17. 17.
    Tazi Mezalek Z, Azzouzi A, Bono W et al (2014) Thromboprophylaxis use and patients in Morocco. Thromb Res 133:725–728CrossRefGoogle Scholar
  18. 18.
    Mokhtari M, Salameh P, Kouchek M (2011) el al. The AVAIL ME Extension: a multinational Middle Eastern survey of venous thromboembolism risk and prophylaxis. J Thromb Haemost 9:1340–1349CrossRefPubMedGoogle Scholar
  19. 19.
    Fuzinatto F, Waldemar FS, Wajner A et al (2013) A clinical decision support system for venous thromboembolism prophylaxis at a general hospital in a middle-income country. J Bras Pneumol 39:138–146CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Bateman AG, Sheaff R, Child S et al (2013) The implementation of NICE guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England. BMC Health Serv Res 13:203CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Duff J, Omari A, Middleton S et al (2013) Educational outreach visits to improve venous thromboembolism prevention in hospitalized medical patients: a prospective before-and-after intervention study. BMC Health Serv Res 13:398CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Jenkins IH, White RH, Amin AN et al (2016) Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five university of California Medical Centers. J Hosp Med 11:S22–S28CrossRefPubMedGoogle Scholar
  23. 23.
    Lester W, Freemantle N, Begaj I et al (2013) Fatal venous thromboembolism associated with hospital admission: a cohort study to assess the impact of a national risk assessment target. Heart 99:1734–1739CrossRefPubMedGoogle Scholar
  24. 24.
    Durieux P, Nizard R, Ravaud P et al (2000) A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. JAMA 283:2816–2821CrossRefPubMedGoogle Scholar
  25. 25.
    Kucher N, Koo S, Quiroz R et al (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 352:969–977CrossRefPubMedGoogle Scholar
  26. 26.
    Roy PM, Rachas A, Meyer G, PREVENU study group (2016) Multifaceted intervention to prevent venous thromboembolism in patients hospitalized for acute medical illness: a multicenter cluster-randomized trial. PLoS ONE 11:e0154832CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Janus E, Bassi A, Jackso D et al (2011) Thromboprophylaxis use in medical and surgical inpatients and the impact of an electronic risk assessment tool as part of a multi-factorial intervention. A report on behalf of the elVis study investigators. J Thromb Thrombolysis 32:279–287CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kahn SR, Morrison DR, Cohen JM et al (2013) Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev. PubMedGoogle Scholar
  29. 29.
    Barbar S, Noventa F, Rossetto V et al (2010) A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 8:2450–2457CrossRefPubMedGoogle Scholar
  30. 30.
    Germini F, Agnelli G, Fedele M et al (2016) Padua prediction score or clinical judgment for decision making on antithrombotic prophylaxis: a quasi-randomized controlled trial. J Thromb Thrombolysis 42:336–339CrossRefPubMedGoogle Scholar
  31. 31.
    Gould MK, Garcia DA, Wren SM et al (2012) Prevention of VTE in non orthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e195S–e226SCrossRefGoogle Scholar
  32. 32.
    Kucher N, Puck M, Blaser J et al (2009) Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patients. J Thromb Haemost 7:1291–1296CrossRefPubMedGoogle Scholar
  33. 33.
    Nendaz MR, Chopard P, Lovis C et al (2010) Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems. J Thromb Haemost 8:1230–1234CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Z. Tazi Mezalek
    • 1
    • 2
  • C. Nejjari
    • 3
  • L. Essadouni
    • 4
  • M. Samkaoui
    • 5
  • K. Serraj
    • 6
  • W. Ammouri
    • 1
    • 2
  • N. Kanjaa
    • 7
  • Z. Belkhadir
    • 8
  • B. Housni
    • 9
  • M. Awab
    • 10
  • M. Faroudy
    • 11
  • W. Bono
    • 12
  • S. Kabbaj
    • 13
  • M. Akkaoui
    • 14
  • M. Barakat
    • 15
  • R. Rifai
    • 16
  • H. Charaf
    • 17
  • A. Aziz
    • 18
  • Y. Elachhab
    • 3
  • A. Azzouzi
    • 10
  1. 1.Department of Internal Medicine/HematologyIbn Sina University HospitalRabatMorocco
  2. 2.Faculty of Medicine and PharmacyMohammed V UniversityRabatMorocco
  3. 3.Laboratory of EpidemiologyClinical Research and Community Health Faculty of Medicine and PharmacyFezMorocco
  4. 4.Internal Medicine Department, Faculty of Medicine and Pharmacy, Mohammed VI University HospitalCadi Ayyad UniversityMarrakechMorocco
  5. 5.Department of Anesthesia, Emergency and Intensive Care Medicine, Faculty of Medicine and Pharmacy, Mohammed VI HospitalCadi Ayyad UniversityMarrakechMorocco
  6. 6.Internal Medicine Department, Faculty of Medicine and Pharmacy, Mohammed VI University HospitalUniversity Mohammed VIOujdaMorocco
  7. 7.Department of Anesthesia Reanimation, Faculty of Medicine and PharmacyHassan II University HospitalFezMorocco
  8. 8.Pole of Anesthesia and Intensive Care, Palliative Care UnitNational Institute of OncologyRabatMorocco
  9. 9.Anesthesia Reanimation DepartmentMohammed VI University HospitalOujdaMorocco
  10. 10.Anesthesia Reanimation DepartmentIbn Sina University HospitalRabatMorocco
  11. 11.Anesthesia Reanimation- Trauma UnitIbn Sina University HospitalRabatMorocco
  12. 12.Internal Medicine DepartmentHassan II University HospitalFezMorocco
  13. 13.Anesthesia Reanimation DepartmentSpecialty HospitalRabatMorocco
  14. 14.Anesthesia ReanimationMohammed V HospitalMeknesMorocco
  15. 15.Anesthesia ReanimationMohammed V HospitalTangierMorocco
  16. 16.Traumatology OrthopedicsMohammed V HospitalMeknesMorocco
  17. 17.Anesthesia ReanimationMohammed V HospitalCasablancaMorocco
  18. 18.Traumatology OrthopedicsMohammed V HospitalCasablancaMorocco

Personalised recommendations