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Hou W, Kong J, Liu L, Han Y, Ren F, Yin S, Huang M, Deng Y, Zhang J, Dai B, Feng X. Incidence of acute Deep Vein Thrombosis in pediatric and adolescent orthopedic trauma hospitalized patients and effect of rivaroxaban treatment. Injury 2024; 55:111710. [PMID: 38976928 DOI: 10.1016/j.injury.2024.111710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/23/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE Deep vein thrombosis (DVT) provoked by orthopedic trauma is increasing in pediatric hospitalized patients. The purpose of our study is to identify the prevalence of acute DVT in pediatric and adolescent orthopedic trauma hospitalized patients and focus on evaluating the anticoagulation strategies and the clinical outcomes after a confirmed acute DVT. METHODS Patients (age ≤18 years) with a confirmed acute DVT admitted for orthopedic trauma between September 2017 and December 2023 were included. Patients were classified into the non-anticoagulation (NA), the in-hospital anticoagulation (IHA), and the in-and-out-of-hospital anticoagulation (IOHA) groups based on their anticoagulation regimen. Efficacy outcomes were the venous thromboembolism (VTE) recurrence within 3 months and change in thrombus burden by repeat imaging at 2 weeks after discharge compared with baseline. Safety outcomes were major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) within 3 months. RESULTS Of the 11,206 pediatric and adolescent orthopedic trauma inpatients, 94(median age,16 [15, 18] years) were diagnosed with acute DVT, with an incidence of 0.84 %, of which 8(8.5 %) received NA, 41(43.6 %) received IHA, and 45(47.9 %) received IOHA. After the diagnosis of DVT, of patients who received anticoagulation, 97.9 % were treated with rivaroxaban as an oral anticoagulant, and 71.7 % received an LMWH course of ≥5 days before starting rivaroxaban therapy. With a median anticoagulation course of 22(8, 37.3) days, the duration in the IOHA was significantly longer than the IHA (37 days vs. 8 days, p = 0.000). No patients experienced recurrent VTE and MB at 3 months, and 1 received IOHA had a CRNMB event (0 % vs. 0 % vs. 2.2 %, p = 1.000). Thrombus resolution was significantly higher in patients who received anticoagulation therapy (IOHA 91.1 % vs. IHA 80.5 % vs. NA 37.5 %, P = 0.002), and thrombus-no relevant change was significantly lower in patients who received the IOHA strategy compared with the other groups (4.4 % vs. 19.5 % vs. 62.5 %, P = 0.000). CONCLUSIONS A rivaroxaban-predominant IOHA strategy significantly reduced the thrombotic burden without increasing the risk of bleeding for the treatment of DVT in adolescents with orthopedic trauma. Duration of anticoagulation therapy <6 weeks appears appropriate for adolescent orthopedic trauma-related DVT.
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Affiliation(s)
- Wei Hou
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China
| | - Jingbo Kong
- Department of Vascular Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Liguo Liu
- Department of Vascular Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Yue Han
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China
| | - Fuji Ren
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Shugang Yin
- Department of Vascular Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Mei Huang
- Department of Vascular Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Yajing Deng
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China
| | - Jinhong Zhang
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China
| | - Bin Dai
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China
| | - Xin Feng
- Department of Pharmacy, Tianjin Hospital, Tianjin 300211, China.
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Wilson HP, Mosha M, Branchford B, Jaffray J, Krava E, Stillings A, Lebensburger J, Goldenberg NA. Recurrent venous thromboembolism in hospitalized children with a history of prior venous thromboembolism: a report from the Children's Hospital-Acquired Thrombosis Consortium. Res Pract Thromb Haemost 2023; 7:102139. [PMID: 37601027 PMCID: PMC10439380 DOI: 10.1016/j.rpth.2023.102139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- Hope P. Wilson
- Department of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maua Mosha
- Data Coordinating Center for Pediatric Multicenter Studies, Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, Florida, USA
| | - Brian Branchford
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplant, Medical College of Wisconsin and Versiti Medical Sciences Institute, Wauwatosa, Wisconsin, USA
| | - Julie Jaffray
- Department of Pediatrics, Rady Children’s Hospital, University of California, San Diego, California, USA
| | - Emily Krava
- Department of Pediatrics, Rady Children’s Hospital, University of California, San Diego, California, USA
| | - Amy Stillings
- Department of Pediatrics, Rady Children’s Hospital, University of California, San Diego, California, USA
| | - Jeffrey Lebensburger
- Department of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Neil A. Goldenberg
- Data Coordinating Center for Pediatric Multicenter Studies, Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, Florida, USA
- Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Thrombosis Program, Johns Hopkins All Children’s Cancer and Blood Disorders Institute, St. Petersburg, Florida, USA
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Efficacy of Early Prophylaxis Against Catheter-Associated Thrombosis in Critically Ill Children: A Bayesian Phase 2b Randomized Clinical Trial. Crit Care Med 2021; 49:e235-e246. [PMID: 33372745 PMCID: PMC7902342 DOI: 10.1097/ccm.0000000000004784] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We obtained preliminary evidence on the efficacy of early prophylaxis on the risk of central venous catheter-associated deep venous thrombosis and its effect on thrombin generation in critically ill children. DESIGN Bayesian phase 2b randomized clinical trial. SETTING Seven PICUs. PATIENTS Children less than 18 years old with a newly inserted central venous catheter and at low risk of bleeding. INTERVENTION Enoxaparin adjusted to anti-Xa level of 0.2-0.5 international units/mL started at less than 24 hours after insertion of central venous catheter (enoxaparin arm) versus usual care without placebo (usual care arm). MEASUREMENTS AND MAIN RESULTS At the interim analysis, the proportion of central venous catheter-associated deep venous thrombosis on ultrasonography in the usual care arm, which was 54.2% of 24 children, was significantly higher than that previously reported. This resulted in misspecification of the preapproved Bayesian analysis, reversal of direction of treatment effect, and early termination of the randomized clinical trial. Nevertheless, with 30.4% of 23 children with central venous catheter-associated deep venous thrombosis on ultrasonography in the enoxaparin arm, risk ratio of central venous catheter-associated deep venous thrombosis was 0.55 (95% credible interval, 0.24-1.11). Including children without ultrasonography, clinically relevant central venous catheter-associated deep venous thrombosis developed in one of 27 children (3.7%) in the enoxaparin arm and seven of 24 (29.2%) in the usual care arm (p = 0.02). Clinically relevant bleeding developed in one child randomized to the enoxaparin arm. Response profile of endogenous thrombin potential, a measure of thrombin generation, was not statistically different between trial arms. CONCLUSIONS These findings suggest the efficacy and safety of early prophylaxis that should be validated in a pivotal randomized clinical trial.
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Koury J, Hellinga R, Rose J, Abraham S, Subbaswamy A. Evaluation of Anticoagulant Monitoring in Pediatric Patients Receiving Enoxaparin for Treatment of Venous Thrombosis. J Pediatr Pharmacol Ther 2021; 26:346-351. [PMID: 34035678 DOI: 10.5863/1551-6776-26.4.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES A venous thromboembolism (VTE) is a blood clot that occurs secondary to vessel wall injury often from a central line insertion. Enoxaparin is often considered a first-line treatment in pediatrics for VTE due to its favorable kinetic profile. Enoxaparin monitoring for pediatric patients is accomplished through anti-Xa monitoring in which monitoring practices may vary between institutions. The objective of this study is to evaluate covariates in pediatric patients to determine which variables are most likely to be associated with enoxaparin dose changes as a result of anti-Xa monitoring. METHODS A single center, retrospective chart review was conducted in pediatric patients treated with enoxaparin for VTE over a 10-year period and who were assessed to determine covariates that lead to dose changes based on anti-Xa levels. Secondary outcomes described monitoring patterns at the University of New Mexico Children's Hospital. RESULTS Sixty-eight patients met inclusion criteria in which results showed that patients aged 2 to 5.9 months (p = 0.026), who had critical care status (p = 0.009), and who were of Native American ethnicity (p = 0.016) were likely to have an enoxaparin dose change at least once during their treatment regimen. The mean number of levels drawn were 7.5 per patient over a 6- to 12-week period, and doses were not frequently changed based on a confirmatory lab draw. However, many doses were adjusted based on the week 1 post-therapeutic level. CONCLUSIONS Patients of Native American ethnicity, younger than 6 months, and those admitted to the PICU were likely to have dose changes based on anti-Xa levels.
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Tian L, Zhang Y, Zeng J, Wang L, Gao H, Su Y, Li Y. A bibliometric analysis of publications on venous thromboembolism in children from 1988 to 2019. Medicine (Baltimore) 2020; 99:e20114. [PMID: 32443321 PMCID: PMC7254855 DOI: 10.1097/md.0000000000020114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) in children not only imposes a heavy burden on the medical resources and economy of the society, but also seriously affects the growth and development of children, even threaten children's lives. A large number of publications have been performed in this field in recent years. In this bibliometric analysis, publications on VTE in children were examined and analyzed to explain the present research hotspots. METHODS Articles related to VTE in children published in the PubMed database from 1988 to June 18, 2019 were selected as the research sample. BICOMB software was used to retrieve the annual publications, journals, journal source countries and the high-frequency major medical subject headings (MeSH) terms on the articles. Then, the co-word matrix was constructed by BICOMB using the selected high-frequency MeSH terms. Next, gCLUTO software was used to analyze the matrix by double clustering and visual analysis in a strategy of hotspot identification. In addition, CiteSpace software was used to perform the knowledge map of co-authors to explore the core authors. RESULTS One thousand seven hundred seventy-nine articles on VTE in children were obtained. Seven hundred ninety academic journals distributed in 58 countries have published articles on VTE in children, and the developed countries and the United States were the major force in the journal source countries. Nowak-Göttl U occupied an important position in this field. We constructed a co-word matrix composing of 37 high-frequency MeSH terms, generated visual matrix and visual hill, and classified the hot-spots into 5 aspects based on 8 categories. CONCLUSION The results show that the research trend of children's VTE has been increasing gradually, and the sound achievement has been obtained in these hotspots in relation to the area of inherited thrombophilia, prevention and control, treatment, diagnosis, prevalence, risk factors, and complication study. However, there is a lack of communication and cooperation in this field, and the gap of national and regional research results is huge. To sum up, this study provides evidence and guidance for researchers, clinicians, and educators.
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Affiliation(s)
- Lingyun Tian
- Xiangya School of Nursing, Central South University, Changsha
- School of Nursing, Anhui University of Chinese Medicine, Hefei
| | - Ying Zhang
- Infection Control Centre, Xiangya Hospital, Central South University, Changsha
| | - Jiaqi Zeng
- Xiangya School of Nursing, Central South University, Changsha
| | - Liqian Wang
- Xiangya School of Nursing, Central South University, Changsha
| | - Huimin Gao
- Xiangya School of Nursing, Central South University, Changsha
| | - Yanan Su
- Xiangya School of Nursing, Central South University, Changsha
| | - Yinglan Li
- Xiangya School of Nursing, Central South University, Changsha
- Department of Nursing, Xiangya Hospital, Central South University, Changsha, China
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Woods GM, Boulet SL, Texter K, Yates AR, Kerlin BA. Venous thromboembolism in chronic pediatric heart disease is associated with substantial health care burden and expenditures. Res Pract Thromb Haemost 2019; 3:372-382. [PMID: 31294324 PMCID: PMC6611372 DOI: 10.1002/rth2.12205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/13/2019] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Background: Venous thromboembolism (VTE) is a complication in children with chronic pediatric heart disease (CPHD). The influence of acute VTE risk factors and the health care burden associated with VTE in CPHD is unknown.Methods: Children <18 years of age with a CPHD diagnostic code were identified from the 2003-2013 MarketScan Commercial Databases. VTE diagnoses were identified either concomitantly with initial CPHD diagnoses or during a 6-month follow-up. The associations between demographic and clinical characteristics and VTE among children with CPHD, stratified by recent cardiac surgery, were assessed by multivariable logistic regression models. Estimates of health care utilization were compared using Wilcoxon rank-sum tests.Results: VTE events occurred in 957 of 120 884 children with CPHD (0.8%). In-hospital mortality was significantly higher in children with VTE. Single-ventricle physiology had the highest VTE rate (2.3%). All comorbid conditions were significantly associated with VTE, but the prevalence was highest in children with recent cardiac (11.1%) or noncardiac surgery (7.8%). The magnitude of association between noncardiac comorbidities and acquired acute cardiovascular conditions and VTE were larger for children without a recent cardiac surgery. Children with VTE had significantly higher health care utilization.Conclusions: VTE in CPHD is associated with significantly increased health care resource utilization and in-hospital mortality. All of the comorbid conditions examined were significantly associated with VTE, but a recent surgical procedure, especially cardiac surgery, conferred the highest VTE risk. Although confounding inherently limits observational studies, these findings provide practical information about the health care costs among patients with CPHD and VTE.
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Affiliation(s)
- Gary M. Woods
- Division of Hematology/Oncology/BMTChildren's Healthcare of AtlantaAtlantaGeorgia
- Department of PediatricsEmory University School of MedicineAtlantaGeorgia
| | - Sheree L. Boulet
- Department of Gynecology and ObstetricsEmory University School of MedicineAtlantaGeorgia
| | - Karen Texter
- Division of CardiologyNationwide Children's HospitalColumbusOhio
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
| | - Andrew R. Yates
- Division of CardiologyNationwide Children's HospitalColumbusOhio
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
| | - Bryce A. Kerlin
- Department of PediatricsCollege of MedicineThe Ohio State UniversityColumbusOhio
- Division of Hematology/Oncology/BMTNationwide Children's HospitalColumbusOhio
- Center for Clinical & Translational ResearchThe Research Institute at Nationwide Children's HospitalColumbusOhio
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Branchford BR, Jaffray J, Mahajerin A. Editorial: Pediatric Venous Thromboembolism. Front Pediatr 2018; 6:269. [PMID: 30320050 PMCID: PMC6170657 DOI: 10.3389/fped.2018.00269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Brian R Branchford
- Department of Pediatrics, Section of Hematology, Oncology at University of Colorado School of Medicine and Children's Hospital Colorado, University of Colorado Hemophilia and Thrombosis Center, Denver, CO, United States
| | - Julie Jaffray
- Division of Hematology, Oncology, BMT, Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Arash Mahajerin
- Division of Hematology, Children's Hospital Orange County Children's Specialists, Orange, CA, United States
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Jaffray J, Mahajerin A, Young G, Goldenberg N, Ji L, Sposto R, Stillings A, Krava E, Branchford B. A multi-institutional registry of pediatric hospital-acquired thrombosis cases: The Children's Hospital-Acquired Thrombosis (CHAT) project. Thromb Res 2018; 161:67-72. [DOI: 10.1016/j.thromres.2017.11.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/06/2017] [Accepted: 11/24/2017] [Indexed: 11/27/2022]
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9
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Rajpurkar M, Biss TT, Amankwah EK, Martinez D, Williams S, van Ommen CH, Goldenberg NA. Pulmonary embolism and in situ pulmonary artery thrombosis in paediatrics. Thromb Haemost 2017; 117:1199-1207. [DOI: 10.1160/th16-07-0529] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/01/2017] [Indexed: 11/05/2022]
Abstract
SummaryData on paediatric pulmonary embolism (PE) are scarce. We sought to systematically review the current literature on childhood PE and conducted a search on paediatric PE via PubMed (1946–2013) and Embase (1980–2013). There was significant heterogeneity in reported data. Two patterns were noted: classic thromboembolic PE (TE-PE) and in situ pulmonary artery thrombosis (ISPAT). Mean age of presentation for TE-PE was 14.86 years, and 51% of cases were males. The commonest method for diagnosis of TE-PE was contrast CT with angiography (74% of patients). The diagnosis of TE-PE was often delayed. Although 85% of children with TE-PE had an elevated D-dimer at presentation, it was non-discriminatory for the diagnosis. In paediatric TE-PE, the prevalence of central venous catheters was 23%, immobilisation 38%, systemic infection 31% and obesity 13%, elevated Factor VIII or von Willebrand factor levels 27%, Protein C deficiency 17%, Factor V Leiden 14% and Protein S deficiency 7%. In patients with TE-PE, pharmacologic thrombolysis was used in 29%; unfractionated heparin was the most common initial anticoagulant treatment in 64% and low-molecular-weight heparins the most common follow-up treatment in 83%. Duration of anticoagulant therapy was variable and death was reported in 26% of TE-PE patients. In contrast to TE-PE, patients with ISPAT were not investigated systematically for presence of thrombophilia, had more surgical interventions as the initial management and were often treated with anti-platelet medications. This review summarises important data and identifies gaps in the knowledge of paediatric PE, which may help to design future studies.
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Knight-Perry J, Branchford BR, Thornhill D, Martiniano SL, Sagel SD, Wang M. Venous thromboembolism in children with cystic fibrosis: Retrospective incidence and intrapopulation risk factors. Thromb Res 2017; 158:161-166. [PMID: 28934665 DOI: 10.1016/j.thromres.2017.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/02/2017] [Accepted: 08/31/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Pediatric venous thromboembolism (VTE) is a rare but serious medical condition. Cystic fibrosis (CF) is a risk for recurrent pediatric VTE and has potential thrombophilic tendency. However, much remains unknown, including incidence and intrapopulation risk factors. METHODS A retrospective cohort of pediatric CF patients followed at Children's Hospital Colorado from January 1st 2003 through May 20th 2016 was examined. Cases were identified by informatics and validated manually. Data on CF severity, co-morbidities and treatment, central venous catheter (CVC) use, and thrombophilia were obtained from an institutional CF database and chart review. RESULTS Nineteen VTE occurred in 458 participants followed for 3595 person-years, yielding an incidence rate of 53 VTE per 10,000 children with CF. VTE cases had additional co-morbidities including CF-related diabetes (p=0.002) and sinus disease (p=0.04), more total admissions (p<0.001), admit days (p<0.001), positive respiratory cultures (p<0.001), pseudomonas infections (p<0.001), steroid courses (p=0.001), and total CVC days (PICC p=0.03, port p=0.007). On univariate analysis, older age (RR 1.162, p=0.007), sinus disease (RR 2.62, p=0.05), longer hospital stay (RR 1.03, p<0.001), higher ESR (RR 1.02, p=0.03) and CRP (RR 1.07, p=0.007), and an absence of systemic steroids (RR 0.19, p=0.004) increased the risk of VTE. CONCLUSIONS In this cohort, children with CF had a higher incidence of VTE when compared to the previously reported incidence in the overall pediatric population at Children's Hospital Colorado. Overall, those with VTE had a greater disease burden and older age, sinus disease, longer hospitalization and increased inflammation were VTE risk factors.
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Affiliation(s)
- Jessica Knight-Perry
- Department of Pediatrics, The Center for Cancer and Blood Disorders, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | - Brian R Branchford
- Department of Pediatrics, The Center for Cancer and Blood Disorders, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA; University of Colorado Hemophilia and Thrombosis Center, Aurora, CO, USA
| | - Dianne Thornhill
- University of Colorado Hemophilia and Thrombosis Center, Aurora, CO, USA
| | - Stacey L Martiniano
- Department of Pediatrics, The Breathing Institute, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | - Scott D Sagel
- Department of Pediatrics, The Breathing Institute, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Wang
- Department of Pediatrics, The Center for Cancer and Blood Disorders, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA; University of Colorado Hemophilia and Thrombosis Center, Aurora, CO, USA.
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Lang K, Patel AA, Munsell M, Bookhart BK, Mody SH, Schein JR, Menzin J. Recurrent hospitalization and healthcare resource use among patients with deep vein thrombosis and pulmonary embolism: findings from a multi-payer analysis. J Thromb Thrombolysis 2016; 39:434-42. [PMID: 25079971 PMCID: PMC4379443 DOI: 10.1007/s11239-014-1108-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The objective of this study was to assess deep vein thrombosis and pulmonary embolism (DVT/PE) recurrence rates and resource utilization among patients with an initial DVT or PE event across multiple payer perspectives. Retrospective analyses were performed using a software tool that analyzes health plan claims to evaluate treatment patterns and resource utilization for various cardiovascular conditions. Six databases were analyzed from three payer perspectives (Commercial, Medicare, and Medicaid). Patients were ≥18 years old with a primary diagnosis of DVT or PE associated with an inpatient and/or emergency room claim, had received an antithrombotic within 7 days before or 14 days after index, and had no diagnosis of atrial fibrillation during follow-up. Outcomes were assessed over a 1 year period following index. More PE patients were hospitalized for their index event than DVT patients (42–59 % DVT and 69–86 % PE) and had longer mean length of stay (2.35–2.95 days DVT and 3.26–3.76 days PE). Recurrent event rates among PE patients (12–32 %) were higher than those for DVT patients (6–16 %) across all payers. The highest rate of recurrence was observed among the Medicaid population [23 % overall (VTE); 16 % DVT; 32 % PE]. All-cause hospitalization in the year following their VTE episode occurred in 23–67 % DVT patients and 30–68 % PE patients. Medicaid had the highest proportion of patients with hospitalizations and ER visits. Recurrent VTE events and all-cause hospitalizations are relatively common, especially for patients who had a PE, and among those in the Medicaid payer population.
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Affiliation(s)
- Kathleen Lang
- Boston Health Economics, Inc, 20 Fox Road, Waltham, MA, 02451, USA
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12
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Grosse SD, Nelson RE, Nyarko KA, Richardson LC, Raskob GE. The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs. Thromb Res 2015; 137:3-10. [PMID: 26654719 DOI: 10.1016/j.thromres.2015.11.033] [Citation(s) in RCA: 323] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/04/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is an important cause of preventable mortality and morbidity. In this study, we summarize estimates of per-patient and aggregate medical costs or expenditures attributable to incident VTE in the United States. Per-patient estimates of incremental costs can be calculated as the difference in costs between patients with and without an event after controlling for differences in underlying health status. We identified estimates of the incremental per-patient costs of acute VTEs and VTE-related complications, including recurrent VTE, post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension, and anticoagulation-related adverse drug events. Based on the studies identified, treatment of an acute VTE on average appears to be associated with incremental direct medical costs of $12,000 to $15,000 (2014 US dollars) among first-year survivors, controlling for risk factors. Subsequent complications are conservatively estimated to increase cumulative costs to $18,000-23,000 per incident case. Annual incident VTE events conservatively cost the US healthcare system $7-10 billion each year for 375,000 to 425,000 newly diagnosed, medically treated incident VTE cases. Future studies should track long-term costs for cohorts of people with incident VTE, control for comorbid conditions that have been shown to be associated with VTE, and estimate incremental medical costs for people with VTE who do not survive. The costs associated with treating VTE can be used to assess the potential economic benefit and cost-savings from prevention efforts, although costs will vary among different patient groups.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, University of Utah Department of Internal Medicine, Salt Lake City, UT, USA
| | - Kwame A Nyarko
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lisa C Richardson
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gary E Raskob
- College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Wisecup S, Eades S, Turiy Y. Characterizing the Risk Factors Associated With Venous Thromboembolism in Pediatric Patients After Central Venous Line Placement. J Pediatr Pharmacol Ther 2015; 20:358-66. [PMID: 26472949 PMCID: PMC4596121 DOI: 10.5863/1551-6776-20.5.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
OBJECTIVES With the apparent increase in venous thromboembolism noted in the pediatric population, it is important to define which children are at risk for clots and to determine optimal preventative therapy. The purpose of this study was to determine the risk factors for venous thromboembolism in pediatric patients with central venous line placement. METHODS This was an observational, retrospective, case-control study. Control subjects were patients aged 0 to 18 years who had a central venous line placed. Case subjects had a central line and a radiographically confirmed diagnosis of venous thromboembolism. RESULTS A total of 150 patients were included in the study. Presence of multiple comorbidities, particularly the presence of a congenital heart defect (34.7% case vs. 14.7% control; p < 0.005), was found to put pediatric patients at increased risk for thrombosis. Additionally, the administration of parenteral nutrition through the central line (34.7% case vs. 18.7% control; p = 0.03) and location of the line increased the risk for clot formation. CONCLUSIONS With increased awareness of central venous line-related thromboembolism, measures should be taken to reduce the number and duration of central line placements, and further studies addressing the need for thromboprophylaxis should be conducted.
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Affiliation(s)
- Sarah Wisecup
- Children's Hospital of San Antonio—Christus Santa Rosa, San Antonio, Texas
| | - Shannan Eades
- Children's Memorial Hermann Hospital, Houston, Texas
| | - Yuliya Turiy
- Children's Memorial Hermann Hospital, Houston, Texas
- University of Texas Health Science Center, Houston, Texas
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Kerlin BA, Smoyer WE, Tsai J, Boulet SL. Healthcare burden of venous thromboembolism in childhood chronic renal diseases. Pediatr Nephrol 2015; 30:829-37. [PMID: 25487668 PMCID: PMC4375065 DOI: 10.1007/s00467-014-3008-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/03/2014] [Accepted: 11/05/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chronic renal diseases (CRD) are associated with approximately 5% of pediatric venous thromboembolism (VTE) cases, but the epidemiology of VTE in CRD is ill-defined. METHODS Children (<18 years) with CRD were identified from MarketScan® Research databases. The VTE status of subjects with CRD who qualified for this study was ascertained during the 6 months following the initial diagnosis of CRD. Demographics, healthcare utilization, mortality, and co-morbid conditions were assessed. RESULTS A total of 22,877 children with predefined CRD ICD-9-CM codes were identified between April 1, 2003 and June 30, 2012, among whom 0.55% had VTE. Our analysis revealed that in-hospital mortality was more likely in children with VTE than in those without VTE (11.9 vs. 0.9%, respectively; p < 0.0001). The usage of healthcare facilities, based on the number of inpatient admissions, length of stay, outpatient visits, and pharmaceutical claims, was also significantly higher in patients with VTE than in those without (p < 0.0001). Total mean healthcare expenditures for the 6-month follow-up period were 13-fold greater in the VTE group than in the group without VTE ($338,338 ± $544,045 vs. $25,171 ± $90,792; p < 0.0001). In a multivariate model, infection, hemodialysis, and trauma/surgery significantly increased the likelihood of VTE. CONCLUSIONS Venous thromboembolism is rare in children with CRD, but it is associated with higher mortality and healthcare utilization when present. Among the children with CRD enrolled in our study, the likelihood of VTE was increased among those with co-morbid, non-renal chronic conditions.
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Affiliation(s)
- Bryce A. Kerlin
- Dept. of Pediatrics, The Ohio State University College of Medicine,Center for Clinical & Translational Research, The Research Institute at Nationwide Children's
| | - William E. Smoyer
- Dept. of Pediatrics, The Ohio State University College of Medicine,Center for Clinical & Translational Research, The Research Institute at Nationwide Children's
| | - James Tsai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention
| | - Sheree L. Boulet
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
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Abstract
OBJECTIVES Although critically ill children are at increased risk for developing deep venous thrombosis, there are few pediatric studies establishing the prevalence of thrombosis or the efficacy of thromboprophylaxis. We tested the hypothesis that thromboprophylaxis is infrequently used in critically ill children even for those in whom it is indicated. DESIGN Prospective multinational cross-sectional study over four study dates in 2012. SETTING Fifty-nine PICUs in Australia, Canada, New Zealand, Portugal, Singapore, Spain, and the United States. PATIENTS All patients less than 18 years old in the PICU during the study dates and times were included in the study, unless the patients were 1) boarding in the unit waiting for a bed outside the PICU or 2) receiving therapeutic anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,484 children in the study, 2,159 (86.9%) had greater than or equal to 1 risk factor for thrombosis. Only 308 children (12.4%) were receiving pharmacologic thromboprophylaxis (e.g., aspirin, low-molecular-weight heparin, or unfractionated heparin). Of 430 children indicated to receive pharmacologic thromboprophylaxis based on consensus recommendations, only 149 (34.7%) were receiving it. Mechanical thromboprophylaxis was used in 156 of 655 children (23.8%) 8 years old or older, the youngest age for that device. Using nonlinear mixed effects model, presence of cyanotic congenital heart disease (odds ratio, 7.35; p < 0.001) and spinal cord injury (odds ratio, 8.85; p = 0.008) strongly predicted the use of pharmacologic and mechanical thromboprophylaxis, respectively. CONCLUSIONS Thromboprophylaxis is infrequently used in critically ill children. This is true even for children at high risk of thrombosis where consensus guidelines recommend pharmacologic thromboprophylaxis.
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16
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Venous thromboembolism in pediatric nephrotic syndrome. Pediatr Nephrol 2014; 29:989-97. [PMID: 23812352 PMCID: PMC6556227 DOI: 10.1007/s00467-013-2525-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 05/18/2013] [Accepted: 05/20/2013] [Indexed: 12/26/2022]
Abstract
Childhood nephrotic syndrome (NS) is one of the most common pediatric kidney diseases, with an incidence of 2-7 per 100,000. Venous thromboembolism (VTE) is associated with significant morbidity and mortality, and occurs in ∼3 % of children with NS, though incidence approaches 25 % in high-risk groups. VTE etiology is multifactorial, with disease-associated coagulopathy thought to be a significant contributor. Other risks include age, disease severity, and treatment-related hazards, such as the presence of central venous catheters. Non-pharmacologic preventive measures such as ambulation and compression stockings are recommended for patients with identified VTE risks. Central venous catheters should be avoided whenever possible. Symptoms of VTE include venous catheter dysfunction, unilateral extremity symptoms, respiratory compromise, flank pain, and gross hematuria. When VTE is suspected, confirmatory imaging studies should be obtained, followed by appropriate laboratory evaluation and treatment. Therapeutic goals include limiting thrombus growth, extension, and embolization by early institution of anticoagulant therapy. Anticoagulation is recommended for a minimum of 3 months, but should be continued until NS remission is achieved. Further studies are necessary to identify VTE-risk biomarkers and optimal therapeutic regimens. Observational cohort studies are needed to identify VTE-risk groups who may benefit from thromboprophylaxis and to define disease-specific treatment algorithms.
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Spentzouris G, Gasparis A, Scriven RJ, Lee TK, Labropoulos N. Natural history of deep vein thrombosis in children. Phlebology 2014; 30:412-7. [PMID: 24837085 DOI: 10.1177/0268355514536154] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the natural history of deep vein thrombosis in children presented with a first episode in the lower extremity veins. METHODS Children with objective diagnosis of acute deep vein thrombosis were followed up with ultrasound and clinical examination. Risk factors and clinical presentation were prospectively collected. The prevalence of recurrent deep vein thrombosis and the development of signs and symptoms of chronic venous disease were recorded. RESULTS There were 27 children, 15 males and 12 females, with acute deep vein thrombosis, with a mean age of 4 years, range 0.1-16 years. The median follow-up was 23 months, range 8-62 months. The location of thrombosis involved the iliac and common femoral vein in 18 patients and the femoral and popliteal veins in 9. Only one vein was affected in 7 children, two veins in 14 and more than two veins in 6. Recurrent deep vein thrombosis occurred in two patients, while no patient had a clinically significant pulmonary embolism. Signs and symptoms of chronic venous disease were present at last follow-up in 11 patients. There were nine patients with vein collaterals, but no patient developed varicose veins. Reflux was found in 18 veins of 11 patients. Failure of recanalization was seen in 7 patients and partial recanalization in 11. Iliofemoral thrombosis (p = 0.012) and failure to recanalize (p = 0.036) increased significantly the risk for developing signs and symptoms. CONCLUSIONS Children with acute proximal deep vein thrombosis develop mild chronic venous disease signs and symptoms at mid-term follow-up and are closely related with iliofemoral thrombosis and failure to recanalization.
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Affiliation(s)
- G Spentzouris
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - A Gasparis
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - R J Scriven
- Section of Pediatric Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - T K Lee
- Section of Pediatric Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - N Labropoulos
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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Zeidler J, Lange A, Braun S, Linder R, Engel S, Verheyen F, Graf von der Schulenburg JM. Die Berechnung indikationsspezifischer Kosten bei GKV-Routinedatenanalysen am Beispiel von ADHS. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56:430-8. [DOI: 10.1007/s00103-012-1624-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Boulet SL, Grosse SD, Thornburg CD, Yusuf H, Tsai J, Hooper WC. Trends in venous thromboembolism-related hospitalizations, 1994-2009. Pediatrics 2012; 130:e812-20. [PMID: 22987875 PMCID: PMC4527304 DOI: 10.1542/peds.2012-0267] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Information on trends in venous thromboembolism (VTE) in US children is scant and inconsistent. We assessed national trends in VTE-associated pediatric hospitalizations. METHODS All nonroutine newborn hospitalizations for children 0 to 17 years of age in the 1994-2009 Nationwide Inpatient Samples were included; routine newborn discharges were excluded. VTE diagnoses were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Variance weighted least square regression was used to assess trends in patient characteristics and rates of hospitalization per 100000 population <18 years of age. Multivariable logistic regression models were used to estimate the probability of VTE diagnosis over the study period. RESULTS The rate of VTE-associated hospitalization increased for all age subgroups (<1, 1-5, 6-11, and 12-17 years), with the largest increase noted among children <1 year of age (from 18.1 per 100000 during 1994 to 49.6 per 100000 during 2009). Compared with 1994-1997, the adjusted odds of hospitalization with a VTE diagnosis were 88% higher during 2006-2009 (adjusted odds ratio: 1.88 [95% confidence interval: 1.64-2.17]). Venous catheter use, mechanical ventilation, malignancy, hospitalization ≥ 5 days, and VTE-related medical conditions were associated with increased likelihood of VTE diagnosis. CONCLUSIONS The rate of VTE-associated hospitalization among US children increased from 1994 through 2009. Increases in venous catheter procedures were associated with and may have contributed to the observed trends. The degree to which increased awareness of VTE influenced the temporal differences could not be determined.
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Affiliation(s)
- Sheree L. Boulet
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Hussain Yusuf
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Tsai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - W. Craig Hooper
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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20
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Kerlin BA. Current and future management of pediatric venous thromboembolism. Am J Hematol 2012; 87 Suppl 1:S68-74. [PMID: 22367975 DOI: 10.1002/ajh.23131] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/17/2012] [Accepted: 01/18/2012] [Indexed: 01/17/2023]
Abstract
Venous thromboembolism (VTE) is an increasingly common complication encountered in tertiary care pediatric settings. The purpose of this review is to summarize the epidemiology, current and emerging pharmacotherapeutic options, and management of this disease. Over 70% of VTE occur in children with chronic diseases. Although they are seen in children of all ages, adolescents are at greatest risk. Pediatric VTE is associated with an increased risk of in-hospital mortality; recurrent VTE and post-thrombotic syndrome are commonly seen in survivors. In recent years, anticoagulation with low molecular weight heparin has emerged as the mainstay of therapy, but compliance is limited by its onerous subcutaneous administration route. New anticoagulants either already approved for use in adults or in the pipeline offer the possibility of improved dose stability and oral routes of administration. Current recommended anticoagulation course durations are derived from very limited case series and cohort data, or extrapolations from adult literature. However, the pathophysiologic underpinnings of pediatric VTE are dissimilar from those seen in adults and are often variable within groups of pediatric patients. Clinical studies and trials in pediatric VTE are underway which will hopefully improve the quality of evidence from which therapeutic guidelines are derived.
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Affiliation(s)
- Bryce A Kerlin
- Division of Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA.
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