The silent crisis: Confronting illness and healthcare-associated venous thromboembolism in India

Venous thromboembolism (VTE), which encompasses deep-vein thrombosis (DVT) and pulmonary embolism (PE), is increasingly being recognised as a global health crisis. Despite its status as the third most common vascular condition after myocardial infarction and stroke,[1] VTE remains chronically under-recognised in India, particularly when it is illness-and healthcare associated venouse thromboembolism (IHAVTE). Globally, IHAVTE is now understood to be the leading cause of preventable hospital deaths and is responsible for a substantial number of adverse clinical outcomes.[2] In India, it represents a ubiquitous vascular ‘hotspot’ and simultaneously, a dangerous clinical blind spot. A 2013 World Health Organization (WHO) publication placed VTE alongside healthcare-associated infections and adverse drug events as one of the three leading preventable causes of harm to hospitalised patients.[2] India’s healthcare system, already strained and ranked 145th globally regarding access and quality,[3] faces significant challenges in addressing this condition. The gravity of the issue is further emphasised by findings that up to 3% of hospitalised patients in India may develop IHAVTE;[2] however, risk-appropriate prophylaxis rates remain dismally low, hovering below 20%.[4] The emerging epidemiology of VTE is alarming. Venous thromboembolism (VTE) is a frequent disease affecting more than 1 in 12 individuals during their lifetime.[5] Approximately 10 million new cases occur globally annually, with up to 60% associated with hospitalisation. IHAVTE includes cases that occur during hospital stay or within 90 days postdischarge. The estimated IHAVTE incidence ranges between 17.5 and 22 per 10,000 hospital admissions[6] in India. Notably, one extensive autopsy-based Indian study found that VTE was the underlying cause of 12% of adult medical deaths.[7] Alarmingly, 80% of these deaths occurred in patients under the age of 40 years and only 10% were suspected to be VTE-caused before death.[7] The morbidity and mortality rates associated with VTE are significant. DVT has a 30-day mortality rate of 3%–6%, and PE has a mortality rate of 12%–30%.[7] Moreover, VTE contributes to up to 10% of all sudden-unexplained hospital deaths in countries like the UK.[8] In India, while comprehensive national data have long been lacking, recent registry-based studies and surveys indicate that the burden is likely similar.[6] The challenges of VTE are its deceptive clinical presentation and lack of awareness. Symptoms are often subtle, nonspecific or absent. Leg pain and swelling due to DVT may be misattributed to musculoskeletal issues. Symptoms of PE – chest pain and shortness of breath, may mimic pneumonia or heart disease.[8] Because of this diagnostic ambiguity, many cases remain undiagnosed or are discovered only after death.[7] Compounding this issue is the near-total absence of structured surveillance for VTE in India until recently. Public awareness campaigns are virtually nonexistent, and clinical suspicion remains low. Traditionally, VTE has not been seen as a disease of public health importance, particularly in non-Caucasian populations.[9] This belief, now thoroughly debunked,[6] has contributed to the decades of under-detection, under-prevention and under-treatment in India. The rise in VTE in India is closely linked to changing demographics, modern lifestyles and increased hospitalisation rates. Risk factors for VTE include older age, cancer, genetic predisposition, obesity, immobility and certain medications.[9] Of these, hospitalisation remains the most significant trigger, especially when accompanied by surgery or prolonged bed rest.[9] Obesity alone accounts for 10%–30% of VTE cases worldwide.[9] Moreover, 30%–50% of Indian patients hospitalised for VTE have no obvious provoking factor, suggesting that unrecognised risk remains widespread.[6] Without proper risk assessment tools, these patients are often entirely missed. In India, the prevalence of unprovoked VTE is high, up to 76%, according to recent studies.[6] Furthermore, approximately 30% of symptomatic VTE cases present as PE,[6] which adds to the urgency of improving diagnostic vigilance and instituting prophylaxis protocols in all healthcare settings. The burden of IHAVTE is not only clinical but also economic. Hospital stays for VTE patients are extended by an average of 3–6 days.[10] In the U.S., this adds thousands of dollars to costs per patient, and similar burdens are likely to exist in India. Indirect costs are equally significant: Additional physician visits, lost productivity, long-term complications such as post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension.[7] The VTE recurrence rate is high. Approximately 10% of patients experience recurrence within 3 months, increasing to 30% within 5–10 years.[7] This chronic nature necessitates long-term anticoagulation and frequent follow-ups, further straining healthcare systems, patient finances as it is attendant with significant morbidity and mortality. Psychologically, many patients, particularly the elderly, experience anxiety regarding anticoagulant therapy. Fear of bleeding and treatment-related stress impact adherence, potentially increasing the risk of recurrence.[10] Despite strong clinical evidence and the availability of effective preventive tools, VTE prevention remains underutilised. Pharmacological prophylaxis – using low-molecular-weight heparin or newer oral anticoagulants – has proven efficacy, reducing PE risk by up to 75% in surgical patients and 57% in medical patients.[4] However, while 50.2% of at-risk patients globally receive guideline-based prophylaxis, the figure for India is only 17.4%.[4] This gap represents a systemic failure to integrate evidence-based practices into routine care in India. Surveys conducted among Indian surgeons have revealed a startling practice of suboptimal prevention and lack of standardisation. A 2013 survey found that although 97% of surgeons had encountered VTE in their careers, only 33% followed an institute-based protocol.[6] The majority admitted that they did not routinely assess preoperative VTE risk. In many cases, the problem is not medical hesitation due to bleeding risk, but systemic inertia and lack of institutional accountability.[6] This failure to implement basic VTE prevention measures reflects a deep gap in clinical governance. The consequences of ignoring IHAVTE are not limited to patient outcomes; they also extend to legal accountability. A review of legal cases in India involving PE-related deaths revealed that several lawsuits led to verdicts against physicians and hospitals for failing to provide prophylaxis.[6] The rising threat of litigation serves as a wake-up call for institutions and practitioners. There is now cautious optimism that India is beginning to address the IHAVTE crisis. The Ministry of Health and Family Welfare, in collaboration with the WHO, has initiated the national response by incorporating VTE surveillance and prevention in the National Patient Safety Implementation Framework (NPSIF) 2018–2025 in April 2018.[11] The National Accreditation Board for Hospitals and Healthcare Providers (NABH) introduced the prevention of VTE in its 5th Edition in April 2020.[12] The launch of the iRegVED VTE registry by the Indian Council of Medical Research in August 2023 represents a turning point.[6] This national registry collects data from hospitals nationwide, laying the groundwork for evidence-based guidelines, policy decisions and clinical benchmarking. In addition, the National Academy of Medical Sciences (NAMS) Registry is also a vital component of the native effort to provide an evidence-based rationale for further action by providing a platform for data collection, analysis and research on VTE in the Indian context.[13] Simultaneously, healthcare accreditation bodies such as NABH, Consortium of Accredited Healthcare Organizations (CAHO) and Joint Commission International (JCI) increasingly emphasise patient safety protocols that include VTE prophylaxis. Leading scientific societies, including The American College of Chest Physicians (ACCP), American Society of Hematology (ASH), International Society on Thrombosis and Haemostasis (ISTH), and NAMS, are pushing for universal risk assessment and standardised hospital protocols.[6] However, policies must now be translated into action at the bedside. India must institutionalise VTE risk assessment and prophylaxis in all tertiary and secondary care settings. Every hospital should have a mandatory policy to first screen all inpatients for VTE risk upon admission. This should be followed by mandatory VTE risk level assessment utilising a clinically validated risk assessment model (RAM), balanced with a bleeding risk assessment, subsequently creating a comprehensive clinical order set (advisory), followed by documentation of prophylaxis and compliance monitoring. In addition, a nationwide public education campaign is overdue. Just as India has seen success with campaigns on tuberculosis, maternal mortality and vaccination, VTE deserves similar attention. Awareness among patients and their families can help facilitate early symptom recognition and improve outcomes. India must also invest in training healthcare workers, including nurses, junior doctors and surgeons, in VTE prevention protocols. Digital health tools and electronic medical record prompts can automate reminders and improve patient compliance. IHAVTE is one of the most preventable, yet devastating conditions in Indian hospitals and has been long identified as one of the top healthcare measures to improve the clinical safety of hospitalised patients in India.[14] The country faces a unique paradox: IHAVTE is increasingly prevalent, widely studied and preventable, yet continues to go under-recognised and under-treated. With mounting clinical evidence, emerging registry data and growing patient safety advocacy, India has the tools and mandate to act. VTE prevention must no longer be optional; it must become a clinical standard and a policy imperative. Continuing to ignore this common and fatal condition is not only a clinical failure; it is a moral one. The time to act is now.