National trends in hospitalizations for venous thromboembolism

Barriers and facilitators to the implementation of guidelines for venous thromboembolism prevention and management: A mixed-methods systematic review

Background

Evidence-based venous thromboembolism prevention and management is a priority for global health services. Low adoption of venous thromboembolism guidelines can result in compromised patient outcomes. Understanding clinicians' and patients' perceptions of barriers to and facilitators for guideline implementation and mapping identified barriers and facilitators to the Consolidated Framework for Implementation Research may inform theoretical interventions to improve guideline adoption rates.

Objective

To synthesize quantitative and qualitative evidence on both 1) perceptions and experiences of hospital clinicians and patients regarding venous thromboembolism practices and 2) barriers to and facilitators for guideline implementation.

Data source

English-language studies from MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane published between 2012 and 2023.

Methods

The included studies primarily focused on two aspects: firstly, elucidating the perceptions and experiences of healthcare providers and patients concerning venous thromboembolism management practices, and secondly, identifying the barriers and facilitators that influence the implementation of venous thromboembolism guidelines. The Mixed Methods Appraisal Tool was used for critical appraisal. Quantitative data were transformed into qualitized data and then thematically synthesized with qualitative data to compare the perspectives of clinicians and patients. Barriers and facilitators related to each topic were mapped to the Consolidated Framework for Implementation Research, and the barriers were entered into its implementation strategy matching tool to obtain implementation strategies.

Results

Of 8262 studies of varying quality, 26 (20 quantitative, five qualitative, and one mixed-methods) met the inclusion criteria. Four themes represented factors influencing guideline implementation: 1) healthcare-led multidisciplinary prevention and management, 2) feasibility of guideline implementation, 3) patient involvement in prevention and management, and 4) government and hospital environments and related systems. The majority of barriers identified by healthcare providers were related to the second and fourth themes, while for patients, there were multiple barriers under the third theme. Barriers were mainly mapped into four domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. Most facilitators mentioned by healthcare providers and patients were related to themes 1, 3, and 4 and mapped to three domains: outer setting, inner setting, and characteristics of individuals. Seven optimal implementation strategies were obtained through the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool.

Conclusions

We highlighted the most influential factors associated with implementing venous thromboembolism guidelines from the perspectives of both clinicians and patients, and mapping these factors to the Consolidated Framework for Implementation Research can help to develop stakeholder-appropriate implementation interventions.

Registration

This study's protocol has been registered at PROSPERO under the registration number CRD42024518184.

Resource utilization and inpatient hospitalization costs associated with thromboembolic events among patients with polycythemia vera

BACKGROUND

Healthcare resource utilization (HCRU) and costs are often elevated in patients with polycythemia vera (PV), and this patient population has an increased risk of developing thromboembolic events (TEs). This study describes HCRU, costs, and mortality during TE-related hospitalizations among patients with PV in a contemporary real-world setting in the United States.

PATIENTS AND METHODS

This retrospective cohort study included adult inpatients with PV and TE discharged from 623 hospitals between January 1, 2017, and June 30, 2020 with a 2-year follow-up period after the first TE-related (index) hospitalization. Data were abstracted from the PINC AI Healthcare database, which includes 25% of US inpatient discharges.

RESULTS

Among 3494 patients (index TE: arterial, 69.1%; venous, 27.1%; both, 3.7%), mean (SD) age was 70.7 (14) years, and most patients were male (58.6%), White (81.2%), with Medicare insurance (72.6%). Mean (SD) Charlson Comorbidity Index score was 3.2 (2.3). Mean total hospitalization costs were $24 403 during the index hospitalization (mean [SD] hospital length of stay [LOS], 7 [9] days). A third (n = 1150) of patients were admitted to the intensive care unit (mean cost, $29 342; mean [SD] LOS, 5 [7] days). During 30 days and 2 years of follow-up, the TE-related readmission rate was 6.4% and 20.0%, respectively. All-cause mortality was 6.2% during index hospitalization; an additional 4.7% occurred during the 2-year follow-up period.

CONCLUSION

Among patients with PV and TE, inpatient hospitalization HCRU, costs, and mortality were substantial. These findings highlight the importance of preventing TEs in the management of PV.

Effectiveness of neuromuscular electrical stimulation on venous thromboprophylaxis in surgical patients: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

The effectiveness of neuromuscular electrical stimulation (NMES) for venous thromboprophylaxis is still debatable. This systematic review and meta-analysis evaluated the effectiveness and safety of NMES among surgical patients undergoing elective surgery.

METHODS

Randomized controlled trials (RCTs) and quasi-experimental studies were retrieved from PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Wanfang, China National Knowledge Infrastructure and Chinese Biomedical Database from their inception to February 1st, 2024. Two reviewers independently assessed, extracted, and appraised the included studies. The meta-analyses incorporated two primary comparisons: NMES versus basic thromboprophylaxis and NMES versus other mechanical thromboprophylaxis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence.

RESULTS

Sixteen studies involving 1685 participants were analysed, with all outcomes being assessed within 14 days postoperatively. Compared with basic thromboprophylaxis and graduated compression stockings, NMES significantly reduced the incidence of postoperative deep venous thrombosis (all p < 0.05). Compared with basic thromboprophylaxis and other mechanical basic thromboprophylaxis, NMES significantly improved postoperative D-dimer level and femoral venous peak velocity (all p < 0.05). No studies reported NMES device-related adverse events. The GRADE results showed low to very low certainty levels of evidence.

CONCLUSION

NMES is a promising mechanical strategy for venous thromboprophylaxis in surgical patients. High-quality RCTs are required to elucidate the therapeutic benefits of NMES compared to other mechanical prevention methods and to standardize its clinical application.

Venous thromboembolism: Why is it still a significant health problem?

BACKGROUND

Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis.

METHODS

We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed.

RESULTS

For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research.

CONCLUSIONS

Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.

Temporal trend in venous thromboembolism hospitalization rates in Brazilian older adults, 2010-2020

Aging is one of the main risk factors for venous thromboembolism (VTE). Changes in prevention, diagnosis, and treatment strategies for this condition in recent years require an analysis of its rates in health services. The objective of this study was to analyze a temporal trend of hospitalizations for VTE in Brazilian older adults. This ecological time series study used data from the Hospital Information System (HIS) on VTE hospitalizations from 2010 to 2020, selecting admissions with the main diagnosis of pulmonary thromboembolism (PTE) (I.26.0, I.26.9) and deep vein thrombosis (DVT) (I.80.0, I80.1, I80.2, I80.3, I80.8, I80.9). Hospitalization rates were calculated for each year and the Prais-Winsten. In Brazil, the trend of hospitalizations for VTE decreased, with an annual percentage change of - 40.71 (confidence interval [CI] - 50.46; - 29.04). DVT decreased, with an annual percentage change of - 43.14 (95% confidence interval [CI] - 51.36; - 33.54). All Brazilian regions showed a downward trend in hospitalizations for VTE and DVT, except for the Northeast region, which remained stable. Conversely, the trend of hospitalizations for PTE showed an upward in Brazil, with an annual percentage change of 4.33 (95% CI 1.26; 7.48). An upward trend was observed in hospitalizations for PTE in the Northeast region, and a stationary trend was observed in the other regions. The results showed a downward trend in hospitalization rates for DVT and an upward trend for PTE. The study indicates regional differences in rates and trends.

Applicability of the Padua scale for Chinese rheumatic in-patients with venous thromboembolism

OBJECTIVE

To investigate the risk factors for venous thromboembolism (VTE) in hospitalized patients with rheumatic diseases in China. The efficacy of the Padua scale was evaluated and an improved model for predicting VTE in hospitalized patients with rheumatic diseases was developed.

METHODS

Records of 2282 patients hospitalized in the department of rheumatology of the Sichuan Provincial People's Hospital were retrospectively reviewed. The risk factors for VTE were analyzed. The efficacy of the Padua scale was evaluated, Padua-combined prediction model and the independent risk factor-combined prediction model for predicting VTE were assessed using the receiver operating curve (ROC).

RESULTS

A total of 50 patients in the VTE group and 2232 in the non-VTE group were included. Antiphospholipid syndrome (APS), VTE history, a hospital stay of over 3 days, high D-dimer (D-D), and decreased serum albumin were independent risk factors for VTE. APS was very closely associated with VTE (OR = 19.446). Padua scores in the VTE group and the non-VTE group were 3 (2, 6) and 2 (1, 2) points, respectively (p < 0.05), and the proportion of high-risk patients were 48.0% and 7.4%, respectively (p < 0.05). The incidence of VTE in the high-risk (Padua score ≥4) and low-risk (Padua score <4) groups was 12.7% and 1.2%, respectively (p < 0.05). The area under curve (AUC) of the Padua scale, Padua combined prediction model (Padua scale along with D-D and serum albumin), and the independent risk factor-combined prediction model was 0.771, 0.836, and 0.873, respectively.

CONCLUSION

The Padua scale has limited predictive efficacy of VTE in hospitalized rheumatic patients. The independent risk factor-combination prediction model was superior in predicting VTE compared to Padua scale and Padua-combined prediction model.

Increasing rates of venous thromboembolism among hospitalised patients with inflammatory bowel disease: a nationwide analysis

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality among patients with inflammatory bowel disease (IBD). However, data on national trends remain limited.

AIMS

To assess national trends in VTE-associated hospitalisations among patients with IBD as well as risk factors for, and mortality associated with, these events METHODS: Using the U.S. Nationwide Inpatient Sample from 2000-2018, temporal trends in VTE were assessed using the National Cancer Institute's Joinpoint Regression Program with estimates presented as the average annual percent change (AAPC) with 95% confidence intervals (CIs).

RESULTS

Between 2000 and 2018, there were 4,859,728 hospitalisations among patients with IBD, with 128,236 (2.6%) having a VTE, and 6352 associated deaths. The rate of VTE among hospitalised patients with IBD increased from 192 to 295 cases per 10,000 hospitalisations (AAPC 2.4%, 95%CI 1.4%, 3.4%, p < 0.001), and remained significant when stratified by ulcerative colitis (UC) and Crohn's disease as well as by deep vein thrombosis and pulmonary embolism. On multivariable analysis, increasing age, male sex, UC (aOR: 1.30, 95%CI 1.26, 1.33), identifying as non-Hispanic Black, and chronic corticosteroid use (aOR: 1.22, 95%CI 1.16, 1.29) were associated with an increased risk of a VTE-associated hospitalisation.

CONCLUSION

Rates of VTE-associated hospitalisations are increasing among patients with IBD. Continued efforts need to be placed on education and risk reduction.

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

IMPORTANCE

Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain.

OBJECTIVE

To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020.

EXPOSURES

ED treatment with a modified clinical decision support tool.

MAIN OUTCOMES AND MEASURES

The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization.

RESULTS

This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%).

CONCLUSIONS AND RELEVANCE

In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.

Treatment and Secondary Prevention of Venous Thromboembolism in Real Clinical Practice Based on Health Care Professional Survey

Aim. To assess the duration of the anticoagulant treatment of venous thromboembolism (VTE) in various categories of patients in real clinical practice through survey of practitioners, as well as correspondence of the duration with current clinical guidelines.

Material and methods. Data obtained from electronic survey of practicing surgeons as part of a commercial brand assessment (Brand Adoption Monitor) was studied. Survey was carried out by the "Validata” analytical agency at the request and with the financial support of Bayer. Inpatient and outpatient vascular surgeons, as well as general outpatient surgeons were invited to complete the electronic questionnaire. The number of interviewed specialists was 100: 50 inpatient vascular surgeons and 50 outpatient specialists, among whom the share of vascular surgeons (phlebologists, angi-ologists) was about 20%. The study was completed in 20 cities of Russia with a population of at least 200,000 people from all federal districts except the North Caucasus and the Republic of Crimea. The selection criteria for participants were: work experience in the specialty ≥3 years, work experience at the current organization >6 months, ≥5 patients with VTE during in the last month.

Results. In total, 104 doctors were surveyed during the period from December 11, 2019 to January 20, 2020, of which 50 were inpatient vascular surgeons and 54 were from outpatient setting. According to the survey of vascular surgeons in hospitals, 75% (6 [5;10]) of patients were hospitalized with a primary episode of VTE and 25% (2 [1;4]) with a recurrent thrombotic event. In an outpatient surgeon, 27.5% (3 [2;5]) of patients were treated in an outpatient setting without hospitalization, 34.7% (3 [2;5]) came to an appointment immediately after discharge from the hospital and 38.8% (2 [1;4]) were a repeat visit regarding a previous VTE. Most often, surgeons observed episodes of clinically unprovoked VTE in 27.3% of cases, thrombotic events provoked by major transient risk factors were 12.2%, event provoked by small transient risk factors were 13.3% and events provoked by small persistent risk factors were 12.6%, while cancer-associated thrombosis represented 13.5%. Most surgeons chose to prescribe anticoagulant therapy beyond 3 months. About half of the specialists prescribed therapy for a year or longer for cancer-associated thrombosis and recurrent VTE. When treating the first episode of clinically unprovoked VTE, about half of the respondents chose anticoagulation for a period of 3 to 6 months. About 60% of specialists prescribed anticoagulant therapy for a period of 3 to 6 months to patients with minor transient or persistent risk factors and patients with VTE provoked by major transient risk factor (trauma or surgery).

Conclusion. Correspondence of the duration of anticoagulant therapy in real clinical practice with the international clinical guidelines varies within 450% range and, on average, does not exceed 30%. This discrepancy was both in situations when the duration of therapy was lower than recommended, but also in situations when treatment extension would not have been recommended.

Persistently High Rate of Venous Thromboembolic Disease in Inflammatory Bowel Disease: A Population-Based Study

INTRODUCTION

Venous thromboembolism (VTE) is known to be increased in inflammatory bowel disease (IBD). We aimed to determine whether rates of VTE in IBD have reduced over the past 30 years.

METHODS

We used the population-based University of Manitoba IBD Epidemiology Database (1984-2018) to determine the incidence of VTE in IBD and the incidence rate ratio vs matched controls. In persons with IBD with and without VTE, we assessed for variables that were associated with an increased risk of VTE on multivariate logistic regression.

RESULTS

The incidence of VTE in the IBD cohort was 7.6% which was significantly greater than in controls (3.3%, P < 0.0001). The overall age-standardized incidence rate of VTE was 433 per 100,000 in IBD and 184 per 100,000 in controls. The incidence of VTE was higher in Crohn's disease (8.4%) than in ulcerative colitis (6.9%, P = 0.0028). The incidence rate ratio in IBD vs controls was 2.36 (95% confidence interval 2.16-2.58). The increased risk was similar in males and females and in Crohn's disease compared with ulcerative colitis. The incidence rate among persons with IBD from 1985 to 2018 decreased very slowly, with annual percent change of -0.7% (P = 0.0003). Hospital admission, high comorbidity, use of antibodies to tumor necrosis factor for less than 3 years up until the time of the VTE, and the combination of steroid and antibodies to tumor necrosis factor increased the risk of VTE.

DISCUSSION

Despite advancements in IBD management in the past 30 years, the rates of VTE have only been slowly decreasing and remain significantly increased compared with controls.

Thrombolytic therapy in acute venous thromboembolism

Although anticoagulation remains the mainstay of treatment of acute venous thromboembolism (VTE), the use of thrombolytic agents or thrombectomy is required to immediately restore blood flow to thrombosed vessels. Nevertheless, systemic thrombolysis has not clearly been shown to improve outcomes in patients with large clot burdens in the lung or legs as compared with anticoagulation alone; this is in part due to the occurrence of intracranial hemorrhage in a small percentage of patients to whom therapeutic doses of a thrombolytic drug are administered. Algorithms have been developed to identify patients at high risk for poor outcomes resulting from large clot burdens and at low risk for major bleeding in an effort to improve outcomes in those receiving thrombolytic therapy. In acute pulmonary embolism (PE), hemodynamic instability is the key determinant of short-term survival and should prompt consideration of immediate thrombolysis. In hemodynamically stable PE, systemic thrombolysis is not recommended and should be used as rescue therapy if clinical deterioration occurs. Evidence is accumulating regarding the efficacy of administering reduced doses of thrombolytic agents systemically or via catheters directly into thrombi in an effort to lower bleed rates. In acute deep venous thrombosis, catheter-directed thrombolysis with thrombectomy can be used in severe or limb-threatening thrombosis but has not been shown to prevent postthrombotic syndrome. Because the management of acute VTE can be complex, having a rapid-response team (ie, PE response team) composed of physicians from different specialties may aid in the management of severely affected patients.

The effect of catheter-directed thrombolytic use on readmission rates and in-hospital outcomes among cancer patients with venous thromboembolism in the United States

BACKGROUND

Cancer inducing a hypercoagulable state, venous thromboembolism (VTE) remains a leading cause of morbidity and mortality globally. We assessed the impacts of cancer on the likelihood for readmission after a VTE-targeted procedure.

METHODS

We created a new cohort using discharge-level data from all hospitalizations from State Inpatient Databases of geographically dispersed participating states (18-27 states).

RESULTS

In those presenting with VTE during index-admission (619 241), 2.4% patients underwent catheter directed thrombolytic therapy (CDL) on index admission and among those 20.3% had cancer. Moreover, the 30-day readmission rate amongst CDL recipients (10 776 overall) was 14.3% in those with cancer compared to 8.8% in those with no cancer history (P < .0001). Additionally, in-hospital mortality (5.7% vs 1.1%; P = 0.009) and cost-of-care ($11 014 ± 914 vs $10 520 ± 534; P = .04) was significantly higher in cancer compared to noncancer.

CONCLUSION

The use of CDL does not appear to reduce the risk of returning for a VTE-related admission in cancer.

Comparison of inpatient admission rates of patients treated with apixaban vs. warfarin for venous thromboembolism in the emergency department

Objectives: This study evaluated inpatient admission status, hospitalization length of stay (LOS), hospital costs, and readmissions of patients who were diagnosed with venous thromboembolism (VTE) and treated with apixaban or warfarin in the emergency department (ED).Methods: Patients (≥18 years) with an ED visit with a primary discharge diagnosis code of VTE were identified from the Premier Hospital database (8/1/2014-5/31/2018). Patients who received apixaban or warfarin during the ED visit were selected and grouped into two treatment cohorts. Outcomes of ED disposition (discharged or admitted to the inpatient setting), hospital LOS, hospital cost of index event, and rate of 1-month readmissions were compared for the study cohorts.Results: Of the overall study population, 30.5% (n = 12,174; mean age: 59.7 years) received apixaban and 69.5% (n = 27,767; mean age: 59.3 years) received warfarin for VTE in the ED. After adjusting for patient and hospital characteristics, the regression analysis showed that apixaban was associated with a significantly lower likelihood of admission to the inpatient setting vs. warfarin (Odds Ratio [OR]: 0.12, 95% Confidence Interval [CI]: 0.12 to 0.13; p < 0.001). Correspondingly, mean index hospital LOS was 1.42 days shorter (95% CI: -1.47 to -1.36; p < 0.001) and mean index event hospital cost per patient was significantly lower by $4,276 ($3,732 [95% CI: $3,565 to $3,907] vs. $8,008 [95% CI: $7,676 to $8,355]; p < 0.001). Also, the likelihood of all-cause 1-month readmission was significantly lower for patients treated with apixaban vs. warfarin (OR: 0.85, 95% CI: 0.79 to 0.92; p < 0.001).Conclusions: In the real-world setting, VTE patients with an ED visit who were treated with apixaban vs. warfarin had a lower likelihood of being admitted to the inpatient setting, which was reflected in shorter average LOS and lower average index event cost. Additionally, the risk of 1-month readmission was also lower for patients treated with apixaban vs. warfarin.

Age-Stratified National Trends in Pulmonary Embolism Admissions

BACKGROUND

Pulmonary embolism (PE) is one of the leading causes of death in hospitalized patients. Treatment patterns and patient demographics for PE are changing; therefore, we sought to evaluate national trends in admission rate, discharge disposition, and length of stay (LOS) in patients hospitalized with PE.

METHODS

The National Inpatient Sample database was used to collect data for hospitalizations of patients ≥ 20 years old with primary diagnosis of PE between January 2000 and September 2015. Patient demographics and hospital characteristics, stratified by patient age, were reported. Trends in rates of hospitalizations for PE, LOS, discharge disposition, and hospital charges were assessed across age groups.

RESULTS

There were an estimated 2,159,568 hospitalizations with primary diagnosis of PE. The rate of PE per 100,000 persons increased by > 100%, and was highest among elderly patients. Increased age and comorbidity burden were independently associated with poor outcomes. Inpatient mortality and LOS decreased across all age groups, but was highest in the elderly. Home health utilization increased in patients ≥ 55 years old. Average hospital charges increased across all age groups, despite shorter length of stay, with patients ≥ 85 experiencing $13,000 average increase.

CONCLUSIONS

Between 2000 and 2015, the rate of hospitalization for PE increased across all age groups. Despite improvements in average LOS and inpatient mortality, hospitalizations became more expensive, and patients required more resources (ie, home health) on discharge. This increased resource utilization was most apparent in elderly patients. This suggests that targeted clinical trials designed to improve outcomes in all age brackets are needed.

The Importance of a Standardized Screening Tool to Identify Thromboembolic Risk Factors in Pediatric Lower Extremity Arthroscopy Patients

INTRODUCTION

Deep vein thrombosis and pulmonary embolism are major complications that can occur in common orthopaedic procedures such as knee arthroscopy. The purpose of this study is to determine the incidence of venous thromboembolism (VTE) risk factors in adolescent patients undergoing elective lower extremity arthroscopy. A second objective is to determine whether a targeted, standardized screening tool is both cost- and clinically effective in the identification of VTE risk factors in adolescents.

METHODS

A standardized VTE screening tool was prospectively administered to all elective arthroscopic procedures in a pediatric sports medicine practice. A comparison cohort that did not complete the screening tool was isolated through a retrospective chart review identifying VTE risk factors. The incidence and cost between the two cohorts were compared.

RESULTS

Of 332 subjects who did not receive a targeted screening (TS) tool, 103 risk factors were noted. One pulmonary embolism case was identified with a total incidence of 0.15% over 3 years. With TS, we identified 325 subjects with 134 identifiable risk factors. Six patients (1.8%) were noted to be very high risk, requiring consultation with hematology. No VTEs were reported. When compared with the retrospective review, TS identified 30% more risk factors. A significant increase in the identification of family history of blood clots (P < 0.001), history of previous blood clot (P = 0.059), recurrent miscarriages in the family (P = 0.010), and smoking exposure (P = 0.062) was found. Additionally, the total cost of screening was less than the cost of prophylaxis treatment with no screening ($20.98 versus $23.51 per person, respectively).

DISCUSSION

Risk factors for VTE may be present in 32.5% of elective adolescent arthroscopic patients. A TS model for VTE identified 30% more risk factors, especially a significant family history, and was shown to be a cost-effective way to safely implement a VTE prevention program.

LEVEL OF EVIDENCE

Level II.

Rate and impact of venous thromboembolism in patients with ST-segment elevation myocardial infarction: Analysis of the Nationwide Inpatient Sample database 2003–2013

Venous thromboembolism (VTE) and coronary artery disease are major health issues that cause substantial morbidity and mortality. New data have emerged suggesting that these two conditions could have a close relationship. Thus, we sought to determine the trends in annual rate of VTE occurrence in patients with ST-segment elevation myocardial infarction (STEMI) and measure its impact on in-hospital mortality, bleeding complications, and cost and length of hospitalization. We queried the 2003–2013 Nationwide Inpatient Sample databases to identify adults with primary diagnosis of STEMI. VTE events were then allocated. Inpatient outcomes of patients with VTE were compared to those without VTE. Out of 2,495,757 hospitalizations for STEMI, VTE was diagnosed in 25,149 (1%) hospitalizations. Patients who experienced VTE were older (mean age: 67.5 vs 64.8, p < 0.01) and had a higher proportion of black patients (10.1% vs 7.7%, p < 0.001) and females (40.1% vs 35%, p < 0.001) compared to patients without VTE. There was an increasing trend in the rate of VTE during the study period (2003: 0.8% vs 2013: 1.0%, p < 0.001). Patients with VTE had a prolonged hospitalization (median: 9 vs 3 days, p < 0.001), increased cost, higher risk of gastrointestinal bleeding (OR: 2.13, p < 0.001), intracranial hemorrhage (OR: 2.14, p < 0.001), blood transfusions (OR: 1.94, p < 0.001), and mortality (OR: 1.39, p < 0.001). The rate of VTE occurrence in patients with STEMI in our study was 10 per 1000 admissions. VTE was associated with more bleeding complications, longer hospital stays, higher costs, and mortality. These findings suggest that a more aggressive approach for VTE prophylaxis may be warranted in this population.

Trends in Hospitalization and In-Hospital Mortality From VTE, 2007 to 2016, in China

BACKGROUND

VTE has emerged as a major public health problem. However, data on VTE burden in China are seldom reported.

METHODS

This study collected data on patients with a principal diagnosis of VTE, pulmonary embolism (PE), or DVT by using the International Classification of Diseases, 10th Revision, from 90 hospitals across China. The trends in hospitalization rates, mortality, length of stay (LOS), and comorbidities from 2007 to 2016 were analyzed.

RESULTS

In total, 105,723 patients with VTE were identified. For patients with VTE, the age- and sex-adjusted hospitalization rate increased from 3.2 to 17.5 per 100,000 population, and in-hospital mortality decreased from 4.7% to 2.1% (P < .001). The mean LOS declined from 14 to 11 days (P < .001). In addition, the data in 2016 showed that the hospitalization rate of VTE was higher in elderly male patients (male patients vs female patients, 155.3 vs 125.4 per 100,000 population in patients aged ≥ 85 years; P < .001) and in northern China (north vs south, 18.4 vs 13.4 per 100,000 population; P < .001). Higher mortality rates were found in patients with cancer and Charlson Comorbidity Index scores > 2. Similar trends were also observed in patients with PE and those with DVT. The hospitalization rate in China was much lower than that of the United States or selected sites in Canada and Europe, the LOS was much longer, and the in-hospital mortality rates were similar.

CONCLUSIONS

The hospitalization rates of VTE increased steadily, and the mortality declined. This study provides important information on the disease burden of VTE in China.

Endovascular and Open Surgery for Deep Vein Thrombosis

The surgical treatment of deep venous thrombosis (DVT) has significantly evolved and is focused on different strategies of early thrombus removal in the acute phase and deep venous recanalization or bypass in the chronic phase. Along with the use of anticoagulation agents, endovascular techniques based on catheter-directed thrombolysis and pharmacomechanical thrombectomy have been increasingly used in patients with acute extensive DVT. Patient selection is crucial to provide optimal outcomes and minimize complications.

Management of venous thromboembolism with non-vitamin K oral anticoagulants: A review for nurse practitioners and pharmacists

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE), comprising deep-vein thrombosis and pulmonary embolism, is associated with significant morbidity and mortality. Non-vitamin K oral anticoagulants (NOACs), including apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban, are as effective and safe as vitamin K antagonists (VKAs) for primary prophylaxis, treatment, and/or secondary prevention of VTE and present significant advantages in convenience of use. This review provides guidance to nurse practitioners (NPs) and pharmacists on NOAC usage for the management of VTE and examines how traditional anticoagulation clinics can adapt to cater to patients on NOACs.

METHODS

A review of the scientific literature pertaining to treatment guideline recommendations, large randomized clinical trials, and real-world evidence studies related to VTE management was conducted.

CONCLUSIONS

With current data suggesting that NOACs may present as better alternatives over VKAs for the management of VTE, comprehensively educating NPs and pharmacists can help incorporate these agents in their clinical practice.

IMPLICATIONS FOR PRACTICE

Repurposing anticoagulation clinics, led by well-informed NPs and pharmacists, will allow effective integration and optimal management of patients with VTE taking NOACs as well as those taking VKAs.

Trends in vena cava filter insertions and "prophylactic" use

BACKGROUND

Prophylactic vena cava filter (VCF) use in patients without venous thromboembolism is common practice despite ongoing controversy. Thorough analysis of the evolution of this practice is lacking. We describe trends in VCF use and identify events associated with changes in practice.

METHODS

Using the National Inpatient Sample, we conducted a retrospective observational study of U.S. adult hospitalizations from 2000 to 2014. Trends in prophylactic VCF insertion were analyzed both across the entire study population and within subgroups according to trauma status and type of concurrent surgery. Annual percentage change (APC) was calculated, and trends were analyzed using Poisson regression.

RESULTS

Among 461,904,314 adult inpatients (median [interquartile range] age, 58.1 [38.5-74.3] years; 39.6% male), the incidence of VCF insertion increased rapidly at first (from 0.19% to 0.35%; APC, 11.2%; 95% confidence interval [CI], 10.3%-12.2%; P < .001), then at a slower rate after the publication of the Prévention du Risque d'Embolie Pulmonaire par Interruption Cave 2 (PREPIC2) trial in 2005 (from 0.35% to 0.42%; APC, 4.4%; 95% CI, 2.8%-6.0%; P < .001), and it began decreasing after the 2010 Food and Drug Administration (FDA) safety alert (from 0.42% to 0.32%; APC, -5.5%; 95% CI, -6.5% to -4.6%; P < .001). The percentage of total VCFs that had a prophylactic indication increased quickly before publication of the PREPIC2 trial (APC, 19.5%; 95% CI, 17.9%-21.0%; P < .001), increased at a slower rate after publication in 2005 (APC, 4.4%; 95% CI, 2.6%-6.2%; P < .001), and dropped after the FDA safety alert, stabilizing at 18.5% for the last 3 years (APC, -0.3%; 95% CI, -2.2% to 1.7%; P = .8). Subgroups most associated with prophylactic VCF insertion were operative trauma (odds ratio [OR], 10.9; 95% CI, 10.2-11.7), orthopedic surgery (OR, 4.7; 95% CI, 4.3-5.2), and neurosurgical procedures (OR, 3.9; 95% CI, 3.6-4.2). All groups except orthopedic surgery experienced a deceleration in prophylactic VCF growth after the publication of PREPIC2. Meanwhile, the FDA safety alert was associated with a decrease in prophylactic VCF insertions for all groups except other major surgery.

CONCLUSIONS

Whereas publication of the PREPIC2 trial led to a deceleration in prophylactic VCF insertion growth, the FDA alert had a bigger impact, leading to declining rates of prophylactic VCF use. Further investigations of prophylactic insertion of VCF in trauma, orthopedic, and neurosurgical patients are needed to determine whether current levels of use are justified.