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Tsaftaridis N, Goldin M, Spyropoulos AC. System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support. J Clin Med 2024; 13:2133. [PMID: 38610898 PMCID: PMC11013003 DOI: 10.3390/jcm13072133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/23/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.
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Affiliation(s)
- Nikolaos Tsaftaridis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY 11030, USA
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Trabulsi N, Khafagy AM, Alhazmi LS, Alghamdi AM, Alzahrani AA, Banaamah MM, Farsi A, Shabkah A, Samkari A, Al-Hajeili M, Abduljabbar A, Wazzan M. Caprini versus Padua venous thromboembolism risk assessment scores: A comparative study in hospitalized patients at a tertiary center. Saudi Med J 2024; 45:362-368. [PMID: 38657986 PMCID: PMC11147578 DOI: 10.15537/smj.2024.45.4.20230954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES To assess and compare the Caprini and Padua risk assessment models (RAMs) for predicting venous thromboembolism (VTE) in hospitalized patients. METHODS We retrospectively reviewed 28 VTE and 450 non-VTE patients hospitalized at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, in 2019. Their baseline medical, demographic, and radiological reports were recorded. We compared Caprini scores (defined at admission) and Padua scores (calculated retrospectively) for their ability to predict VTE. A cumulative risk score was created by adding the individual scores for each risk factor. We also analyzed the sensitivity, specificity, and diagnostic accuracy of the RAM scores. RESULTS Major differences in risk factors were shown between patients with and without VTE. Previous VTE was significantly associated with a higher risk of VTE (28.6%), as was reduced mobility (57.1%), acute infection (25%), high Caprini score (50%), and high Padua score (64.3%, p<0.05). The sensitivity of the Caprini score (96%) was higher than that of the Padua score (64.3%), as was the specificity (92.1% vs. 46.9%), positive predictive value (93% vs. 7%), and accuracy (94.1% vs. 47.9%). The specificity of the Caprini score was higher than that of the Padua score in Critical Care, Gynecology/Obstetrics, and Surgical departments. The Caprini RAM showed the lowest level of specificity in the medical department. CONCLUSION The Caprini RAM demonstrated higher sensitivity, specificity, and predictive accuracy than did the Padua RAM and thus distinguished low and high VTE risk in hospitalized patients.
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Affiliation(s)
- Nora Trabulsi
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Abdulmajeed M. Khafagy
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Lenah S. Alhazmi
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Abdullah M. Alghamdi
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Abdulmajeed A. Alzahrani
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Mohanned M. Banaamah
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Ali Farsi
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Alaa Shabkah
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Ali Samkari
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Marwan Al-Hajeili
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Ahmed Abduljabbar
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
| | - Mohammad Wazzan
- From the Department of Surgery (Trabulsi, Alhazmi, Alzahrani, Samkari, Farsi); from the Department of Internal Medicine (Khafagy, Al-Hajeili); from the Department of Radiology (Banaamah, Abduljabbar, Wazzan), Faculty of Medicine, King Abdulaziz University, from the Department of Internal Medicine (Alghamdi), King Abdulaziz University Hospital, and from the Department of Surgery (Shabkah), International Medical Center, Jeddah, Kingdom of Saudi Arabia.
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Al Jahwari A, Al Rawahi B. Venous Thromboembolism Risk and Prophylaxis in the Acute Hospital Care Settings in Oman: A National Multicenter Cross-sectional Study. Oman Med J 2024; 39:e614. [PMID: 38988795 PMCID: PMC11234340 DOI: 10.5001/omj.2024.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/28/2023] [Indexed: 07/12/2024] Open
Abstract
Objectives To evaluate the prevalence of risk for venous thromboembolism (VTE) and the proportion of at-risk patients who receive appropriate thromboprophylaxis among inpatients in acute hospital care settings in Oman. A related objective was to evaluate the type and time of initiation of VTE prophylaxis. Methods This multicenter, cross-sectional study was conducted in three tertiary hospitals in Oman. The study included acutely ill medical and surgical inpatients admitted from August to September 2022. VTE risk assessment and prophylaxis were assessed based on the 2012 recommendations of the American College of Chest Physicians (ACCP). Results A total of 384 patients were enrolled, 240 were medical patients and 144 were surgical patients. As per the ACCP criteria, 179 (74.6%) of medical and 92 (63.9%) of surgical patients were at risk for VTE and required prophylaxis. Appropriate prophylaxis was received by 142 (79.3%) at-risk medical and 70 (76.1%) at-risk surgical patients. In cases where pharmacological prophylaxis was contraindicated, mechanical prophylaxis was markedly underused. For medical patients, the median day of initiating VTE prophylaxis was day one of admission. For surgical patients, the median day of initiating VTE prophylaxis was postoperative day one. Conclusions The majority of hospitalized patients in Oman are at risk of VTE. However, a significant minority of patients do not receive the required pharmacological or mechanical prophylaxis. We recommend the development of a national VTE risk assessment and guiding tool with a facility for monitoring compliance.
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Affiliation(s)
- Asma Al Jahwari
- Hematopathology Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | - Bader Al Rawahi
- Hematopathology Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
- Hematology Department, Sultan Qaboos University Hospital, Muscat, Oman
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Spyropoulos AC, Goldin M, Koulas I, Solomon J, Qiu M, Ngu S, Smith K, Leung T, Ochani K, Malik F, Cohen SL, Giannis D, Khan S, McGinn T. Universal EHRs Clinical Decision Support for Thromboprophylaxis in Medical Inpatients: A Cluster Randomized Trial. JACC. ADVANCES 2023; 2:100597. [PMID: 38938337 PMCID: PMC11198051 DOI: 10.1016/j.jacadv.2023.100597] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/18/2023] [Accepted: 06/23/2023] [Indexed: 06/29/2024]
Abstract
Background Thromboprophylaxis for medically ill patients during hospitalization and postdischarge remains underutilized. Clinical decision support (CDS) may address this need if embedded within workflow, interchangeable among electronic health records (EHRs), and anchored on a validated model. Objectives The purpose of this study was to assess the clinical impact of a universal EHR-integrated CDS tool based on the International Medical Prevention Registry on Venous Thromboembolism plus D-Dimer venous thromboembolism model. Methods This was a cluster randomized trial of 4 tertiary academic hospitals from December 21, 2020 to January 21, 2022. Inpatients over age 60 with key medical illnesses were eligible. We embedded CDS at admission and discharge. Hospitals were randomized to intervention (CDS; n = 2) vs usual care (n = 2) groups. The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included venous, arterial, and total thromboembolism, major bleeding, and all-cause mortality through 30 days postdischarge. Results After exclusions, 10,699 of 19,823 patients were analyzed. Intervention group tool adoption was 77.8%. Appropriate thromboprophylaxis was increased at intervention hospitals, both inpatient (80.1% vs 72.5%, OR: 1.52, 95% CI: 1.39-1.67) and at discharge (13.6% vs 7.5%, OR: 1.93, 95% CI: 1.60-2.33). There were fewer venous (2.7% vs 3.3%, OR: 0.80, 95% CI: 0.64-1.00), arterial (0.25% vs 0.70%, OR: 0.35, 95% CI: 0.19-0.67), and total thromboembolisms (2.9% vs 4.0%, OR: 0.71, 95% CI: 0.58-0.88) at intervention hospitals. Major bleeding was rare and did not differ between groups. Mortality was higher at intervention hospitals (9.1% vs 7.0%, OR: 1.32, 95% CI: 1.15-1.53). Conclusions EHR-embedded CDS increased appropriate thromboprophylaxis and reduced thromboembolism without increasing major bleeding in medically ill inpatients. Mortality was higher at intervention hospitals.
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Affiliation(s)
- Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Ioannis Koulas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jeffrey Solomon
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Michael Qiu
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sam Ngu
- Department of Hematology/Oncology, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Kolton Smith
- Department of Internal Medicine, Lenox Hill Hospital at Northwell Health, New York, New York, USA
| | - Tungming Leung
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, Hempstead, New York, USA
| | - Kanta Ochani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Fatima Malik
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Stuart L. Cohen
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Department of Radiology, North Shore University Hospital at Northwell Health, Manhasset, New York, USA
| | - Dimitrios Giannis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas, USA
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- CommonSpirit Health, Chicago, Illinois, USA
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Sonderman M, Wells QS. Closing the Gap in VTE Prophylaxis: The Role of Clinical Decision Support. JACC. ADVANCES 2023; 2:100601. [PMID: 38938335 PMCID: PMC11198200 DOI: 10.1016/j.jacadv.2023.100601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Mark Sonderman
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Quinn S. Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ratnasekera A, Geerts W, Haut ER, Price M, Costantini T, Murphy P. Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:490-494. [PMID: 36729882 PMCID: PMC9974883 DOI: 10.1097/ta.0000000000003850] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.
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Affiliation(s)
- Asanthi Ratnasekera
- From the Department of Surgery (A.R.), Division of Trauma and Surgical Critical Care, Drexel College of Medicine, Philadelphia, Pennsylvania; Christianacare Health (A.R.), Newark, Delaware; Thromboembolism Program, Sunnybrook Health Sciences Centre, Department of Medicine (W.G.), University of Toronto, Toronto, Canada; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland, Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine Baltimore, Maryland; Department of Health Policy and Management (E.R.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Coalition for National Trauma Research (M.P.), San Antonio, Texas; Division of Trauma, Surgical Critical Care and Burn Surgery, Department of Surgery (T.C.), University of California San Diego, California; and Division of Trauma and Acute Care Surgery, Department of Surgery (P.M.), Medical College of Wisconsin, Milwaukee, Wisconsin
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Gelcho GN, Bekele MG. Modeling Time to Cure of Deep Vein Thrombosis Using Cox Proportional Model in Southwest of Ethiopia. Ethiop J Health Sci 2022; 32:555-562. [PMID: 35813688 PMCID: PMC9214733 DOI: 10.4314/ejhs.v32i3.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background Globally, there are about 10 million cases of deep vein thrombosis every year, and it is the third leading cardiovascular disease after myocardial infarction and stroke. The objective of the study is to assess risk factors of time to cure patients of deep vein thrombosis in southwest Ethiopia. Methods A retrospective cohort study design was used. The study population was deep vein thrombosis patients at purposively selected hospitals in Southwest Ethiopia from January 2017 to December 2020. Cox proportional hazard model was used to identify risk factors associated with deep vein thrombosis. Results Out of the total 1068 registered as deep vein thrombosis patients, 263(24.6%) were cured during the study period, and 805(75.4%) were censored. Results of the Cox proportional hazard model show that; age, gender, family history of deep vein thrombosis, smoking status, immobilize and alcohol consumption were factors associated with deep vein thrombosis (p-value<0.05). Conclusion The patients with a family history of deep vein thrombosis, prolonged immobilization, greater the 50 years, smoking cigarettes, female (non-pregnant) and alcohol users had a longer curing time of deep vein thrombosis compared to others.
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Affiliation(s)
- Gurmessa Nugussu Gelcho
- Department of Statistics, College of Natural Sciences, Jimma University, Jimma, Oromia, Ethiopia
| | - Mosisa Girma Bekele
- Department of Statistics, College of Natural Sciences, Jimma University, Jimma, Oromia, Ethiopia
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Intagliata NM, Davitkov P, Allen AM, Falck-Ytter YT, Stine JG. AGA Technical Review on Coagulation in Cirrhosis. Gastroenterology 2021; 161:1630-1656. [PMID: 34579937 DOI: 10.1053/j.gastro.2021.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Perica Davitkov
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan G Stine
- Liver Center, Division of Gastroenterology and Hepatology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Chen X, Deng H, Tong X, Gu B, Liu J, Huang H, Ye L, Pan L, Caprini JA, Wang Y. Clinical Validation of the Chinese Version of Patient Completed Caprini Risk Assessment Form. Clin Appl Thromb Hemost 2021; 26:1076029620945038. [PMID: 32816523 PMCID: PMC7444100 DOI: 10.1177/1076029620945038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To create and validate patient-completed Caprini risk score (CRS) tools for Chinese people. We revised Chinese patient-completed CRS form according to previously published studies. We prospectively recruited 70 internal medical patients and 70 surgical patients. The average age of these patients was 54.26 ± 15.29 years, 54.29% of them were male and 80% of them had education beyond high school. The study compared: (1) patient-completed CRS and physician-completed CRS; (2) the final value of physician-completed CRS (physician-completed CRS + body mass index) and CRS in the electronic medical record (EMR) system. Patient-completed CRS was 3.71 ± 3.63, patients spent 3.60 ± 1.24 minutes, 57.14% patients were at high-highest risk; physician-completed CRS was 3.84 ± 3.63, physicians spent 2.11 ± 1.13 minutes, 59.28% patients were at high-highest risk; the final value of physician-completed CRS was 4.12 ± 3.62, 63.58% patients were at high-highest risk; CRS value in the EMR system was 4.07 ± 3.58, 65% patients were at high-highest risk. There were strong positive correlations (P < .0001) between patient-completed CRS and physician-completed CRS (r = 0.978, κ = 0.76) and between the final value of physician-completed CRS and CRS in EMR (r = 0.994, κ = 0.97). This study successfully developed and validated a Chinese patient-completed CRS that we found can replace physician-completed CRS. This results in considerable time saving for physicians and this process should increase the percentage of patients having complete risk assessment when they are admitted to the hospital.
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Affiliation(s)
- Xiaolan Chen
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Deng
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xinjie Tong
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Bei Gu
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingxuan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - He Huang
- Department of Hospital Affairs, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Liwei Ye
- Department of Hospital Affairs, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lei Pan
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Joseph A Caprini
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA.,NorthShore University HealthSystem, Evanston, IL, USA
| | - Yong Wang
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China.,Beijing Emergency Medical Center, Beijing, People's Republic of China
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Jara-Palomares L, Jiménez D, Bikdeli B, Muriel A, Rali P, Yamashita Y, Morimoto T, Kimura T, Le Mao R, Riera-Mestre A, Maestre A, Moustafa F, Monreal M. Derivation and validation of a clinical prediction rule for thrombolysis-associated major bleeding in patients with acute pulmonary embolism: the BACS score. Eur Respir J 2020; 56:2002336. [PMID: 32703772 DOI: 10.1183/13993003.02336-2020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Improved prediction of the risk of major bleeding in patients with acute pulmonary embolism (PE) receiving systemic thrombolysis is crucial to guide the choice of therapy. METHODS The study included consecutive patients with acute PE who received systemic thrombolysis in the RIETE registry. We used multivariable logistic regression analysis to create a risk score to predict 30-day major bleeding episodes. We externally validated the risk score in patients from the COMMAND VTE registry. We also compared the newly created risk score against the Kuijer and RIETE scores. RESULTS Multivariable logistic regression identified four predictors for major bleeding: recent major Bleeding (3 points), Age >75 years (1 point), active Cancer (1 point), and Syncope (1 point) (BACS). Among 1172 patients receiving thrombolytic therapy in RIETE, 446 (38%) were classified as having low-risk (none of the variables present, 0 points) of major bleeding according to the BACS score, and the overall 30-day major bleeding rate of this group was 2.9% (95% CI, 1.6-4.9%), compared with 44% (95% CI, 14-79%) in the high-risk group (>3 points). In the validation cohort, 51% (149/290) of patients were classified as having low-risk, and the overall 30-day major bleeding rate of this group was 1.3%. In RIETE, the 30-day major bleeding event rates in the Kuijer and RIETE low-risk stratum were 5.3% and 4.4%, respectively. CONCLUSIONS The BACS score is an easily applicable aid for prediction of the risk of major bleeding in the population of PE patients who receive systemic thrombolysis.
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Affiliation(s)
- Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital. New York, USA
- Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA
- Cardiovascular Research Foundation, New York, USA
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Parth Rali
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, USA
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Raphael Le Mao
- EA3878, Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Université Européenne de Bretagne, Brest, France
| | - Antoni Riera-Mestre
- Department of Internal Medicine, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Ana Maestre
- Department of Internal Medicine, Hospital del Vinalopó, Elche, Spain
| | - Fares Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Manuel Monreal
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
- Universidad Católica de Murcia, Murcia, Spain
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11
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Abboud J, Abdel Rahman A, Kahale L, Dempster M, Adair P. Prevention of health care associated venous thromboembolism through implementing VTE prevention clinical practice guidelines in hospitalized medical patients: a systematic review and meta-analysis. Implement Sci 2020; 15:49. [PMID: 32580777 PMCID: PMC7315522 DOI: 10.1186/s13012-020-01008-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous VTE prevention clinical practice guidelines are available but not consistently implemented. This systematic review explored effectiveness of implementing VTE prevention clinical practice guidelines on VTE risk assessment and appropriateness of prophylaxis in hospitalized adult medical patients and identified the interventions followed to improve the adherence to these guidelines. METHODS Six electronic databases were searched for randomized controlled trials, clinical controlled trials, or pre/post evaluation studies up to January 2019. Studies identified were screened for eligibility by two reviewers independently. Data were extracted by two reviewers using a standardized form. Risk of bias was assessed using MINORS and the certainty of evidence for each outcome using the GRADE approach. RESULTS Of the 3537 records identified, 36 were eligible; eight studies were included for qualitative synthesis and four for meta-analysis. The meta-analysis of the studies assessing the impact of implementing VTE clinical practice guidelines favored appropriate prophylaxis (RR 1.67, 95% CI 1.41 to 1.97, 552 patients). Potential risk of bias was assessed to be low for 28% of the studies. However, using GRADE, the certainty of the evidence of all outcomes was rated very low quality. CONCLUSIONS The lack of randomized controlled trials in this area reduces the quality of the evidence available. The evidence from before-after studies suggests that the implementation of VTE clinical practice guidelines may increase the practice of VTE risk assessment and appropriate prophylaxis in hospitalized medical patients. TRIAL REGISTRATION PROSPERO CRD42018085506.
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Affiliation(s)
- Juliana Abboud
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast, BT9 5BN UK
| | - Abir Abdel Rahman
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Balamand, Ashrafieh, Youssef Sursok Street, PO Box 166378, Beirut, Lebanon
| | - Lara Kahale
- AUB GRADE Center, Clinical Research Institute, American University of Beirut, Academic and Clinical Center (ACC), 3rd floor, Riad El Solh, PO Box: 11-0236, Beirut, 1107 2020 Lebanon
| | - Martin Dempster
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast, BT9 5BN UK
| | - Pauline Adair
- Centre for Improving Health Related Quality of Life, School of Psychology, Queens University Belfast, David Keir Building, 18-30 Malone Road, Belfast, BT9 5BN UK
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12
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Ruiz-Talero P, Cerón-Perdomo D, Hernández-Flórez C, Gutiérrez-gómez S, Muñoz-Velandia O. Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients. Int J Qual Health Care 2020; 32:319-324. [DOI: 10.1093/intqhc/mzaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program.
Design
Longitudinal before and after study.
Setting
Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia).
Participants
Adult nonsurgical hospitalized patients.
Intervention
A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program.
Main Outcome Measure
Appropriate use of thromboprophylaxis.
Results
221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005).
Conclusions
Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.
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Affiliation(s)
- Paula Ruiz-Talero
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Daniela Cerón-Perdomo
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Catalina Hernández-Flórez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Santiago Gutiérrez-gómez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Oscar Muñoz-Velandia
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
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13
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Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative. Am J Med 2020; 133 Suppl 1:1-27. [PMID: 32362349 DOI: 10.1016/j.amjmed.2019.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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14
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Kanjee Z, Bauer KA, Breu AC, Burns R. Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 172:484-491. [PMID: 32252085 DOI: 10.7326/m20-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is a common and potentially fatal condition. Medical inpatients are at high risk for VTE because of immobility as well as acute and chronic illness. Several randomized trials demonstrated that chemoprophylaxis, or low-dose anticoagulation, prevents VTE in selected medical inpatients. The 2018 American Society of Hematology clinical practice guideline on prophylaxis for hospitalized and nonhospitalized medical patients conditionally recommends chemoprophylaxis for non-critically ill medical inpatients, leaving much to the discretion of the treating physician. Here, 2 experts, a hematologist and a hospitalist, reflect on the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., K.A.B., R.B.)
| | - Kenneth A Bauer
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., K.A.B., R.B.)
| | - Anthony C Breu
- Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts (A.C.B.)
| | - Risa Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.K., K.A.B., R.B.)
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15
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Kahn SR, Diendéré G, Morrison DR, Piché A, Filion KB, Klil-Drori AJ, Douketis J, Emed J, Roussin A, Tagalakis V, Morris M, Geerts W. Effectiveness of interventions for the implementation of thromboprophylaxis in hospitalised patients at risk of venous thromboembolism: an updated abridged Cochrane systematic review and meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024444. [PMID: 31129575 PMCID: PMC6537979 DOI: 10.1136/bmjopen-2018-024444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 01/30/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of venous thromboembolism (VTE) in hospitalised medical and surgical patients at risk of VTE. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, PubMed, Embase, BIOSIS, CINAHL, Web of Science, CENTRAL, DARE, EED, LILACS and clinicaltrials.gov without language restrictions from inception to 7 January 2017, as well as the reference lists of relevant review articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES RCTs that evaluated the effectiveness of system-wide interventions such as alerts, multifaceted, education, and preprinted orders when compared with no intervention, existing policy or another intervention. RESULTS We included 13 RCTs involving 35 997 participants. Eleven RCTs had data available for meta-analysis. Compared with control, we found absolute increase in the prescription of prophylaxis associated with alerts (21% increase, 95% CI [15% to 275%]) and multifaceted interventions (4% increase, 95% CI [3% to 11%]), absolute increase in the prescription of appropriate prophylaxis associated with alerts (16% increase, 95% CI [12% to 20%]) and relative risk reductions (risk ratio 64%, 95% CI [47% to 86%]) in the incidence of symptomatic VTE associated with alerts. Computer alerts were found to be more effective than human alerts, and multifaceted interventions with an alert component appeared to be more effective than multifaceted interventions without, although comparative pooled analyses were not feasible. The quality of evidence for improvement in outcomes was judged to be low to moderate certainty. CONCLUSIONS Alerts increased the proportion of patients who received prophylaxis and appropriate prophylaxis, and decreased the incidence of symptomatic VTE. Multifaceted interventions increased the proportion of patients who received prophylaxis but were found to be less effective than alerts interventions. TRIAL REGISTRATION NUMBER CD008201.
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Affiliation(s)
- Susan R Kahn
- Medicine, McGill University, Montreal, Quebec, Canada
| | - Gisele Diendéré
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - David R Morrison
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Alexandre Piché
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada
| | | | - Adi J Klil-Drori
- Medicine, McGill University, Montreal, Quebec, Canada
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - James Douketis
- Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Emed
- Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - André Roussin
- Medicine, University of Montreal, Montreal, Quebec, Canada
- Thrombosis Canada, Whitby, Ontario, Canada
| | - Vicky Tagalakis
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Internal Medicine and Medicine, McGill University, Montreal, Quebec, Canada
| | - Martin Morris
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | - William Geerts
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Nemeth B, Lijfering WM, Nelissen RGHH, Schipper IB, Rosendaal FR, le Cessie S, Cannegieter SC. Risk and Risk Factors Associated With Recurrent Venous Thromboembolism Following Surgery in Patients With History of Venous Thromboembolism. JAMA Netw Open 2019; 2:e193690. [PMID: 31074822 PMCID: PMC6512304 DOI: 10.1001/jamanetworkopen.2019.3690] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The size of the risk of recurrent venous thromboembolism (VTE) after surgery in patients with a history of VTE is not well known. OBJECTIVES To estimate the risk of and to identify the factors associated with recurrent VTE in patients undergoing surgery who have a history of VTE. DESIGN, SETTING, AND PARTICIPANTS This population-based, follow-up cohort study includes patients with VTE who participated in the Multiple Environment and Genetic Assessment (MEGA) study. Original data were collected from March 1999 to April 2010. Data analysis began in June 1999 and ended in April 2010. EXPOSURES Surgery following a first VTE. MAIN OUTCOMES AND MEASUREMENTS Kaplan-Meier analyses were used to estimate cumulative incidences of recurrent VTE. Cox regression with a time-dependent covariate (surgery) was used to calculate the hazard ratio (HR) for developing recurrent VTE after surgery compared with no surgery. RESULTS Overall, 3741 patients (mean [SD] age, 48.4 [12.8] years; 2020 [54.0%] women) with a history of VTE were included in the analysis, amounting to 18 899 person-years, with a median (interquartile range) follow-up of 5.7 (3.0-7.2) years. Of the 3741 patients, 580 (15.5%) underwent surgery and 601 (16.1%) developed a recurrent thrombotic event. The 1-month cumulative incidence of recurrent VTE for all surgery types was 2.1% (95% CI, 1.2%-3.6%), which increased to 3.3% (95% CI, 2.1%-5.1%) at 3 months and 4.6% (95% CI, 3.1%-6.6%) at 6 months. At 6 months, risk of recurrent VTE ranged from 2.3% to 9.3%, depending on surgery type. In addition to surgery type, factor V Leiden mutation (HR, 3.4; 95% CI, 1.6-7.4) and male sex (HR, 2.7; 95% CI, 1.3-5.8) were associated with increased risk of recurrent VTE. CONCLUSIONS AND RELEVANCE Surgery was associated with an increased risk of recurrent VTE in patients with a history of VTE; risk remained high for up to 6 months after the procedure. This study suggests that high-risk individuals may be identified based on surgery type, sex, and the presence of factor V Leiden mutation. These findings stress the need for revision of the current thromboprophylactic approach to prevent recurrence in these patients.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M. Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G. H. H. Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Inger B. Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Medical Statistics, Department of Biomedical Datascience, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Chen X, Pan L, Deng H, Zhang J, Tong X, Huang H, Zhang M, He J, Caprini JA, Wang Y. Risk Assessment in Chinese Hospitalized Patients Comparing the Padua and Caprini Scoring Algorithms. Clin Appl Thromb Hemost 2018; 24:127S-135S. [PMID: 30198321 PMCID: PMC6714840 DOI: 10.1177/1076029618797465] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The current venous thromboembolism (VTE) guidelines recommend all patients to be assessed for the risk of VTE using risk assessment models (RAMs). The study was to evaluate the performance of the Caprini and Padua RAMs among Chinese hospitalized patients. We reviewed data from 189 patients with deep venous thrombosis (DVT) and 201 non-DVT patients. Deep venous thrombosis risk factors were obtained from all patients. The sensitivity and specificity of the Caprini and Padua scores for all patients were calculated. The receiver operating curve (ROC) and the area under the ROC curve (AUC) were used to evaluate the performance of each score. We documented that age, acute infection, prothrombin time (PT), D-dimer, erythrocyte sedimentation rate, blood platelets, and anticoagulation were significantly associated with the occurrence of DVT (P < .05). These results were true for all medical and surgical patients group (G1), as well as the analysis of medical versus surgical patients (G2). Finally, analysis of the scores in patients with and without cancer was also done (G3). The Caprini has a higher sensitivity but a lower specificity than the Padua (P < .05). Caprini has a better predictive ability for the first 2 groups (P < .05). We found Caprini and Padua scores have a similar predictive value for patients with cancer (P > .05), while Caprini has a higher predictive ability for no cancer patients in G3 than Padua (P < .05). For Chinese hospitalized patients, Caprini has a higher sensitivity but a lower specificity than Padua. Overall, Caprini RAM has a better predictive ability than Padua RAM.
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Affiliation(s)
- Xiaolan Chen
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lei Pan
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Deng
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingyuan Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xinjie Tong
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - He Huang
- Department of Hospital Affairs, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Min Zhang
- Department of Hospital Affairs, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jianlin He
- Epigenomics and Computational Biology Lab, Biocomplexity Institute of Virginia Tech, Blacksburg, VA, USA
| | - Joseph A Caprini
- University of Chicago Pritzker School of Medicine, Chicago IL, USA.,NorthShore University HealthSystem, Evanston IL, USA
| | - Yong Wang
- Department of Respiratory and Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
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Currow DC, Smith JM, Chansriwong P, Noble S, Nikolaidou T, Ferreira D, Johnson MJ, Ekström M. Missed opportunity? Worsening breathlessness as a harbinger of death: a cohort study. Eur Respir J 2018; 52:13993003.00684-2018. [DOI: 10.1183/13993003.00684-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 07/12/2018] [Indexed: 12/13/2022]
Abstract
The aim of the study was to explore trajectories of breathlessness intensity by function and life-limiting illness diagnosis in the last 3 weeks of life in palliative care patients.A prospective, consecutive cohort study obtained point-of-care data of patients of Silver Chain Hospice Care Service (Perth, Australia) over the period 2011–2014 (n=6801; 51 494 data-points). Breathlessness intensity (0–10 numerical rating scale) and physical function (Australia-modified Karnofsky Performance Status (AKPS)) were measured at each visit. Time was anchored at death. Breathlessness trajectory was analysed by physical function and diagnosis using mixed effects regression.Mean±sdage was 71.5±15.1 years and 55.2% were male, most with cancer. The last recorded AKPS was >40 for 26.8%. Breathlessness was worst in people with cardiorespiratory disease and AKPS >40, and breathlessness in the last week of life increased most in this group (adjusted mean 2.92versusall others 1.51; p=0.0001). The only significant interaction was with diagnosis and function in the last week of life (p<0.0001).Breathlessness is more intense and increases more in people with better function and cardiorespiratory disease immediately before death. Whether there are reversible causes for these people should be explored prospectively. Omitting function from previous population estimates may have overestimated breathlessness intensity for many patients in the days preceding death.
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19
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Mahan CE, Burnett AE, Fletcher ML, Spyropoulos AC. Extended thromboprophylaxis in the acutely ill medical patient after hospitalization - a paradigm shift in post-discharge thromboprophylaxis. Hosp Pract (1995) 2017; 46:5-15. [PMID: 29171776 DOI: 10.1080/21548331.2018.1410053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Venous thromboembolism (VTE) is a significant healthcare burden with approximately 900,000 events annually in the United States, over half of which are healthcare-associated. This number is anticipated to double by 2050. Group prophylaxis strategies confined to the inpatient setting appear to have minimal impact on the reduction of post-discharge VTE in medically ill patients due to shortened lengths of stay and a heterogenous population that includes patients at low risk for VTE. In accordance with current guideline recommendations, very few (<5%) medically ill patients are discharged with extended prophylaxis, which potentially creates a clinical gap for at-risk patients as VTE risk has been shown to persist for up to 90 days. Initial studies of extended thromboprophylaxis in acutely ill medical patients with enoxaparin, rivaroxaban and apixaban showed little to no benefit towards VTE reduction that was consistently outweighed by increased bleeding. The more recent APEX study that compared betrixaban to enoxaparin in an enriched patient population at high-risk for VTE was the first study of extended thromboprophylaxis that showed similar efficacy in VTE prevention without an increase in major bleeding. Based on the APEX results, betrixaban recently gained FDA approval for extended thromboprophylaxis in acutely ill medical patients. Recognition that up to half of medically ill patients are not at sufficient risk to warrant thromboprophylaxis has driven extensive research towards development of scientifically derived and validated VTE risk assessment models intended to identify patients who do not warrant prophylaxis, as well as those at high risk who may derive benefit from extended thromboprophylaxis. This article will review prior and ongoing extended thromboprophylaxis studies, VTE and bleed risk assessment models, incorporation of biomarkers in VTE risk assessment and key issues in the paradigm shift towards individualized VTE prophylaxis in acutely ill medical patients.
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Affiliation(s)
- Charles E Mahan
- a Hospital Pharmacy , Presbyterian Healthcare Services, University of New Mexico , Albuquerque , NM , USA
| | - Allison E Burnett
- b Hospital Pharmacy , University of New Mexico Health Sciences Center , Albuquerque , NM , USA
| | - Meghan L Fletcher
- b Hospital Pharmacy , University of New Mexico Health Sciences Center , Albuquerque , NM , USA
| | - Alex C Spyropoulos
- c Hofstra Northwell School of Medicine, Department of Medicine , Northwell Health System at Lenox Hill Hospital , New York , NY , USA
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Individualized Venous Thromboembolism Risk Stratification Using the 2005 Caprini Score to Identify the Benefits and Harms of Chemoprophylaxis in Surgical Patients: A Meta-analysis. Ann Surg 2017; 265:1094-1103. [PMID: 28106607 DOI: 10.1097/sla.0000000000002126] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We performed a meta-analysis to investigate benefits and harms of chemoprophylaxis among surgical patients individually risk stratified for venous thromboembolism (VTE) using Caprini scores. SUMMARY OF BACKGROUND DATA Individualized VTE risk stratification may identify high risk surgical patients who benefit from peri-operative chemoprophylaxis. METHODS MEDLINE, EMBASE, and the Cochrane Library (CENTRAL) databases were queried. Eligible studies contained data on postoperative VTE and/or bleeding events with and without chemoprophylaxis. Primary outcomes included rates of VTE and clinically relevant bleeding after surgical procedures, stratified by Caprini score. A meta-analysis was conducted using a random-effects model. RESULTS Among 13 included studies, 11 (n = 14,776) contained data for VTE events and 8 (n = 7590) contained data for clinically relevant bleeding with and without chemoprophylaxis. The majority of patients received mechanical prophylaxis. A 14-fold variation in VTE risk (from 0.7% to 10.7%) was identified among surgical patients who did not receive chemoprophylaxis, and patients at increased levels of Caprini risk were significantly more likely to have VTE. Patients with Caprini scores of 7 to 8 [odds ratio (OR) 0.60, 95% confidence interval (95% CI) 0.37-0.97] and >8 (OR 0.41, 95% CI 0.26-0.65) had significant VTE risk reduction after surgery with chemoprophylaxis. Patients with Caprini scores ≤6 comprised 75% of the overall population, and these patients did not have a significant VTE risk reduction with chemoprophylaxis. No association between postoperative bleeding risk and Caprini score was identified. CONCLUSIONS The benefit of peri-operative VTE chemoprophylaxis was only found among surgical patients with Caprini scores ≥7. Precision medicine using individualized VTE risk stratification helps ensure that chemoprophylaxis is used only in appropriate surgical patients and may minimize bleeding complications.
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Wendelboe AM, St. Germain L, Krolak B, Reiser T, Raskob G. Impact of World Thrombosis Day campaign. Res Pract Thromb Haemost 2017; 1:138-141. [PMID: 30046683 PMCID: PMC6058210 DOI: 10.1002/rth2.12021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/19/2017] [Indexed: 11/16/2022] Open
Abstract
Thrombosis is an underlying cause of one in four deaths globally. The International Society on Thrombosis and Haemostasis established the inaugural World Thrombosis Day on October 13, 2014. The World Thrombosis Day campaign aims to 1) highlight the disease burden from thrombosis, 2) increase public awareness of the risks, signs, and symptoms of thromboembolic conditions, 3) empower individuals to discuss their thrombosis risk with their healthcare provider, 4) galvanize organizations across the globe, and 5) advocate for "systems of care" to prevent, diagnose, and treat venous thromboembolism and atrial fibrillation. Public health messages include: "know the risks, signs, and symptoms of blood clots," "potentially fatal blood clots in the veins can be prevented," "atrial fibrillation can be diagnosed by a doctor feeling one's pulse," and "effective strategies for stroke prevention in patients with atrial fibrillation are available." To demonstrate the public health impact of the World Thrombosis Day campaign, we measured campaign reach, size and breadth of our partner network, as well as traditional and digital media impressions. The campaign reached an estimated ≥2.3 billion people globally in 2016. As part of the World Thrombosis Day campaign, approximately 8,200 activities were held globally and our partner network expanded to ≥675 partners across 80 countries in 2016. Social media metrics reached 170 million impressions and traditional media reached 1.9 billion impressions. We appreciate and thank our partners for their contributions and encourage others to support this campaign to reduce thrombosis-related morbidity and mortality worldwide.
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Affiliation(s)
- Aaron M. Wendelboe
- College of Public HealthUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | | | - Barbara Krolak
- International Society on Thrombosis and HaemostasisCarrboroNCUSA
| | - Thomas Reiser
- International Society on Thrombosis and HaemostasisCarrboroNCUSA
| | - Gary Raskob
- College of Public HealthUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
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Abstract
Acutelly-ill hospitalised medical patients are at risk of venous thromboembolism (VTE), both in-hospital and in the immediate post-discharge period, and mortality from VTE is thought to be particularly high in this patient population. However, despite previous mandates from international antithrombotic guidelines such as those of the American College of Chest Physicians (ACCP) for the "universal" use of thromboprophylaxis in hospitalised medical patients, global audits suggest that implementation of thromboprophylaxis continues to be challenging because of the perceived higher risk of bleeding and lower risk of VTE than that reported in clinical trials. Recent population-based studies also reveal that a "universal" hospital-only thromboprophylactic strategy does not reduce the community burden of VTE from this population, which may constitute nearly one quarter of the attributable risk of VTE. Lastly, four large randomised placebo-controlled trials of extended thromboprophylaxis have failed to show a definitive net clinical benefit in hospitalised medical patients. Recent large-scale efforts in deriving and validating scored VTE and bleed risk assessment models (RAMs) have been completed in the medically-ill population. In addition, an elevated D-dimer as a new biomarker to identify at-VTE risk medically ill patients has also undergone prospective evaluation. This paper will review current concepts of VTE and bleed risk in hospitalised medical patients, both in the hospital as well as the post-hospital discharge period, and will discuss new paradigms of thromboprophylaxis in this population using an individualised, patient-centered approach.
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Affiliation(s)
- Alex C Spyropoulos
- Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC, Professor of Medicine - Hofstra Northwell School of Medicine, Professor - The Merinoff Center for Patient-Oriented Research, The Feinstein Institute for Medical Research, System Director - Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, 130 E 77th St, New York, NY 10075, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
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Gibson CM, Spyropoulos AC, Cohen AT, Hull RD, Goldhaber SZ, Yusen RD, Hernandez AF, Korjian S, Daaboul Y, Gold A, Harrington RA, Chi G. The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification. TH OPEN 2017; 1:e56-e65. [PMID: 31249911 PMCID: PMC6524839 DOI: 10.1055/s-0037-1603929] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The IMPROVE score is a validated venous thromboembolism (VTE) assessment tool to risk stratify hospitalized, medically ill patients based on clinical variables. It was hypothesized that addition of D-dimer measurement to derive a new IMPROVEDD score would improve identification of at risk of VTE. Methods The association of the IMPROVE score and D-dimer ≥ 2 × the upper limit of normal (ULN) with the risk of symptomatic deep vein thrombosis, nonfatal pulmonary embolism, or VTE-related death was evaluated in 7,441 hospitalized, medically ill patients randomized in the APEX trial. Based on the Cox regression analysis, the IMPROVEDD score was derived by adding two points to the IMPROVE score if the D-dimer was ≥ 2 × ULN. Results Baseline D-dimer was independently associated with symptomatic VTE through 77 days (adjusted HR: 2.22 [95% CI: 1.38-1.58], p = 0.001). Incorporation of D-dimer into the IMPROVE score improved VTE risk discrimination (ΔAUC: 0.06 [95% CI: 0.02-0.09], p = 0.0006) and reclassification (continuous NRI: 0.34 [95% CI: 0.17-0.51], p = 0.001; categorical NRI: 0.13 [95% CI: 0.03-0.23], p = 0.0159). Patients with an IMPROVEDD score of ≥2 had a greater VTE risk compared with those with an IMPROVEDD score of 0 to 1 (HR: 2.73 [95% CI: 1.52-4.90], p = 0.0007). Conclusion Incorporation of D-dimer into the IMPROVE VTE risk assessment model further improves risk stratification in hospitalized, medically ill patients who received thromboprophylaxis. An IMPROVEDD score of ≥2 identifies hospitalized, medically ill patients with a heightened risk for VTE through 77 days.
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Affiliation(s)
- C. Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alex C. Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, New York, United States
| | - Alexander T. Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, United Kingdom
| | - Russell D. Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Alberta, Canada
| | - Samuel Z. Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Roger D. Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Adrian F. Hernandez
- Department of Medicine, Duke University and Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Serge Korjian
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Yazan Daaboul
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alex Gold
- Portola Pharmaceuticals, Inc., South San Francisco, California, United States
| | - Robert A. Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, United States
| | - Gerald Chi
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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Roberts LN, Durkin M, Arya R. Annotation: Developing a national programme for VTE prevention. Br J Haematol 2017; 178:162-170. [PMID: 28542789 DOI: 10.1111/bjh.14769] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The National Venous Thromboembolism Prevention Programme was launched in England, in 2010. Its central objective was to reduce morbidity and mortality from preventable deep vein thrombosis and pulmonary embolism through introduction of a comprehensive systematic approach. The cornerstone of the programme was the introduction of mandatory documented risk assessment for venous thromboembolism, supported by national thromboprophylaxis guidance. Despite widespread uptake of risk assessment, measuring the impact of the national programme on outcomes has proved challenging. The aim of this paper is to review the implementation and outcomes of the national programme.
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Affiliation(s)
- Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Mike Durkin
- NHS National Director of Patient Safety, NHS Improvement, London, UK.,Institute for Global Health Innovation, Imperial College, London, UK
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
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Lip GYH, Weber C. A happy and prosperous New Year 2017 with "Thrombosis and Haemostasis" …. and our 60 th Anniversary! Thromb Haemost 2017; 117:1-2. [PMID: 28066853 DOI: 10.1160/th16-12-0903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 01/24/2023]
Affiliation(s)
- Gregory Y H Lip
- Prof. Gregory Y. H. Lip, University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK, E-mail:
| | - Christian Weber
- Prof. Christian Weber, Institute for Cardiovascular Prevention, Ludwig-Maximilians-University, Pettenkoferstr. 9, 80336 Munich, Germany, E-mail:
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