Delays in diagnosis and treatment of venous thromboembolism in a developing country setting

Bulgular: Semptomların başlangıcından tedavi başlanmasına kadarki ortalama süre 4.70 gündü, bu sürenin %89’u semptomların başlangıcından ilk medikal değerlendirmeye kadar geçen süreydi (ortalama= 4.19 gün). Semptomların başlangıcından tanının doğrulanmasına kadarki ortalama süre 6.29 gündü. Venöz tromboembolizmli 353 hastanın 185 (%52.4)’i semptomların başlangıcından sonra ilk iki günde, 168 (%47.6)’i iki günden sonra bir klinisyen tarafından değerlendirildi. Erken değerlendirme ile ilişkili olan ve p değeri < 0.05 olan faktörler, yüksek eğitim düzeyi, yakın zamanda cerrahi, alçı varlığı, bacakta şişmeydi ve pulmoner tromboembolizmli hastaların derin ven trombozlu hastalara göre daha erken değerlendirildiği saptandı. Yaş, cinsiyet, semptom sayısı ve venöz tromboembolizm yönünden aile öyküsü ile ilişki yoktu (p> 0.05). Yüksek olasılık skorlu hastalarda ilk değerlendirmeden tanıya kadar geçen süre anlamlı olarak daha kısaydı.


INTRODUCTION
Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) are acute disease.Acute PTE is the cause of 50.000 to 200.000 death annually in the USA (1).Its mortality reported to be about 13% in first month and 35.3% within three years after diagnosis.As many as 95% of PTE related deaths occur prior to diagnosis or within hours of the event (2)(3)(4).One study showed that patients diagnosed within 48 hours had better outcomes (5).
Despite the stated facts about VTE, delays in diagnosis and initiating treatment are a common problem.A study in USA reported delays in diagnosis in approximately 20% of patients with VTE.However, data about delays in the diagnosis of VTE in a developing country are sparse.
The aim of this study is to determine delays in diagnosis and treatment of VTE, and related factors in a developing country setting.

MATERIALS and METHODS
We prospectively investigated 353 consecutive patients with imaging confirmed diagnosis DVT and/or PTE from May 2008 to August 2012.It was conducted at Imam Khomeini Hospital, a tertiary care hospital at Urmia University of Medical Sciences (Iran).It was approved by the university research council.The following information was collected: a. Demographic data: i.e., age, sex, level of education, b.Dates includes: the date of symptom onset, the date that the subject was first seen by medical personnel for these symptoms, the date that VTE treatment initiated, and the date on which the diagnosis was confirmed with imaging, c.Presence of temporary risk factors for VTE at the time of symptoms onset and their relation with delays, d.DVT or PTE probability scoring parameters on the day of admission to our center score (6,7).

Definition of Terms
1. Patients delay: Interval in days between onsets of symptoms to first seeking medical attention.It categorized as early, visit within two days of onsets of symptoms and late: after second day of symptoms onset.

Diagnosis delay:
Interval in days between first day seeking medical attention to final confirmatory imaging.It categorized as early, confirmation within first two days and late after second day of first seeking medical help.

Total diagnosis delay:
Interval in days between first onsets of symptoms to final confirmatory imaging.

Statistical Analysis
SPSS version 18 software is used.Baseline characteristics are reported by descriptive analysis.Chi-square test is used to analyze the difference in frequencies between two groups.p values < 0.05 are considered to be significant.

DISCUSSION
Our study shows that mean interval between onsets of VTE symptoms to initiation of treatment is near to five days.This is while that it has been confirmed that early diagnosis and treatment reduces mortality for acute PTE (8).It may also decrease the development of the post-phlebitis syndrome, and, chronic pulmonary hypertension following PTE (9,10).Non-specific symptoms and signs of VTE mimic other illnesses, and PTE is known as "the Great Masquerader," making diagnosis difficult even for experienced physicians.
In current study, most of the delay in the diagnosis and treatment of VTE represented the delay from symptom onset to the date of first medical evaluation.(16).
In a study in Turkey the mean time from symptoms onset to the first admission to a health institution among patients with PTE was about 2.04 days which were shorter than our study for PTE patients (3.05 days) (12).
In a study by Jimenez Castro, of the 397 patients with acute PTE, 72 (18%) had a diagnostic delay while 325 (82%) did not, the median time from symptom onset to diagnosis was 7 days and 6% patients had a delay of more than 25 days (13).
In Ireland, among 60 patients with PTE near to 50% of patients presented within 24 hours of onset of symptom, and 25% after one week (14).In current study, 31.9% of patients with PTE presented on day of onset of symptoms, which indicate a bad condition in a developing country setting.
A study in Turkey among 156 with PTE showed that, 60.3% of them were admitted to a hospital within the first 24 hours of onset of symptom (12).In our study this rate was lower (22.2% for DVT and 31.9% for PTE).
In our study the delays from the date of first medical evaluation to the start of treatment is shorter than confirmation of VTE.It is a encouraging finding because guidelines recommend initiation of anticoagulation if clinical suspicion for PTE is high, even prior to confirmatory testing (15).Finding of this study, emphasis importance and essential role of public education for fast diagnosis and treatment of DVT and PTE.Similar to other common and serious disorders such as myocardial infarction, lay persons should learn to suspect for PTE for any unexplained shortness of breath, chest pain.
We conclude that there was a considerable delay from the onset of VTE symptoms to initiation of treatment, patients delays in seeking medical help constitute most part of this delay.Patients with high probability for VTE had earlier diagnosis.We suggest improving lay person's awareness about DVT and PTE, and their alarming symptoms.

FrequencyFigure 1 . 1 :
Figure 1.Delays in days from onset of symptoms to first visit by a physician (0 means on the same day of onset of symptoms, 1: One day later, 2: Two days later, …).

Table 1 . Demographic data of 353 patients.
Of 264 patients with DVT 52 (22.2%) found medical advice on the day of event and 58 (25%) patients after one week while patients with PTE 38 (31.9%) on day of symptom onset 16 (13.4%)afteroneweekvisitedby a physician.Of 353 patients with VTE 185 (52.4%) visited by a physician within two days of onset of symptoms and 168 (47.6%) patients visited after two days.The comparison of related factors for these two groups is shown in Table3.We found no difference in the gender and in the mean age of the two groups.The-Delays in diagnosis and treatment of venous thromboembolism in a developing country setting 98Tuberk Toraks 2013; 61(2): 96-102

Table 2 . Timing intervals in days for delays.
nal diagnosis of PTE within first two days of visit was 5.33 ± 2.55 and for 47 patients with final diagnosis after the first two visit day was 3.96 ± 2.55 (p= 0.006).Patients with Wells probability score intermediate and high had earlier diagnosis than those with low probability (p= 0.024).Table 5 summarized diagnosis delay relation to Wells PTE probability scoring parameters.

Table 3 . Comparison early (n= 185) and delayed (n= 168) for medical evaluation from onset of VTE symptoms.
* Early: Within 2 days of onset of symptoms; Delayed: More than 2 days after onset of symptoms.

Table 5 . Relation of delay from first visit to final diagnosis to PTE score.
Early: Confirmation of diagnosis within first 2 days of seeking medical attention, delayed: more than 2 days after onset of symptoms (By definition in this study).** A point score < 2: low probability, 2-6 points intermediate probability, and > 6 points high probability. *