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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 351] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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Kline JA, Adler DH, Alanis N, Bledsoe JR, Courtney DM, d'Etienne JP, Diercks DB, Garrett JS, Jones AE, Mackenzie DC, Madsen T, Matuskowitz AJ, Mumma BE, Nordenholz KE, Pagenhardt J, Runyon MS, Stubblefield WB, Willoughby CB. Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial. Circ Cardiovasc Qual Outcomes 2021; 14:e007600. [PMID: 34148351 DOI: 10.1161/circoutcomes.120.007600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial. METHODS This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes. RESULTS We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled. CONCLUSIONS Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.)
| | - David H Adler
- Department of Emergency Medicine, University of Rochester, NY (D.H.A.)
| | - Naomi Alanis
- Department of Emergency Medicine, University of North Texas, Denton (N.A.)
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT (J.R.B.)
| | - Daniel M Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas (D.M.C., D.B.D.)
| | - James P d'Etienne
- Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX (J.P.d.)
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, Dallas (D.M.C., D.B.D.)
| | - John S Garrett
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX (J.S.G.)
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi, Jackson (A.E.J.)
| | - David C Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland (D.C.M.)
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah, Salt Lake City (T.M.)
| | - Andrew J Matuskowitz
- Department of Emergency Medicine, Medical University of South Carolina, Charleston (A.J.M.)
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis (B.E.M.)
| | | | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University, Morgantown (J.P.)
| | - Michael S Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, NC (M.S.R.)
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville TN (W.B.S.)
| | - Christopher B Willoughby
- Department of Internal Medicine, Division of Emergency Medicine, Louisiana State University, New Orleans (C.B.W.)
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Stein PD, Matta F, Hughes MJ. Site of Deep Venous Thrombosis and Age in the Selection of Patients in the Emergency Department for Hospitalization Versus Home Treatment. Am J Cardiol 2021; 146:95-98. [PMID: 33529621 DOI: 10.1016/j.amjcard.2021.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 11/24/2022]
Abstract
Despite apparent advantages of home treatment of deep venous thrombosis (DVT) based upon results of randomized controlled trials, physicians maintain a conservative approach, and a large proportion of patients with DVT are hospitalized. In the present investigation we assess whether selection of patients for hospitalization for acute DVT was related to the site of the DVT or to age. This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample, 2016. Patients were identified by International Classification of Diseases-10-Clinical Modification codes. Most, 87,436 of 133,414 (66%), had proximal DVT. A minority of patients with isolated distal DVT were hospitalized, 10,621 of 37,592 (28%). However, hospitalization was selected for 47,459 of 87,436 (54%) with proximal DVT; 4,867 of 7,599 (64%) with pelvic vein DVT; and 611 of 788 (78%) with DVT involving the inferior vena cava. Hospitalization for patients with distal DVT, proximal DVT, and pelvic vein DVT was age-dependent. In conclusion, both the site of acute DVT and age were factors affecting the clinical decision of emergency department physicians to select patients for hospital treatment.
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Trocio J, Rosen VM, Gupta A, Dina O, Vo L, Hlavacek P, Rosenblatt L. Systematic literature review of treatment patterns for venous thromboembolism patients during transitions from inpatient to post-discharge settings. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 11:23-49. [PMID: 30588051 PMCID: PMC6305128 DOI: 10.2147/ceor.s179080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Direct oral anticoagulants (DOACs) have emerged as viable alternatives to traditional treatments such as vitamin K antagonists (VKAs) for venous thromboembolism (VTE). The objective of this review was to summarize evidence on the use of DOACs and VKAs to treat VTE in the US for patients transitioning from inpatient to post-discharge settings. Materials and methods A systematic review of the VTE literature identified studies published in English (January 1, 2011–December 31, 2016) that reported inpatient and post-discharge treatments and discharge location. Two reviewers screened abstracts, abstracted information from included studies, and assessed the quality of the study methodology and reporting. Results Forty-nine studies were included (24 clinical and 25 economic). A limited number of studies (eight clinical and three economic) examined VTE treatment patterns during transitions of care from inpatient to post-discharge settings, irrespective of anticoagulant (eg, DOAC, warfarin, heparin), and < 25% of all studies reported a post-discharge location. Three clinical studies that reported inpatient and outpatient treatment found better patient outcomes with DOAC vs warfarin. Fourteen economic studies reported that DOACs were associated with shorter hospital length of stay (LOS) and lower direct costs vs warfarin. No studies reported indirect costs. Discussion Although DOACs are associated with shorter LOS, lower costs, and better patient outcomes vs VKAs, it appears in one study that only a small percentage of patients with stable VTE who are discharged to home may be receiving DOACs. Conclusion These findings identified the potential areas of opportunity to improve the management of VTE through coordination of care from the inpatient to the outpatient settings.
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Affiliation(s)
- Jeffrey Trocio
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Virginia M Rosen
- Health Economics and Outcomes Research, Optum Inc., Eden Prairie, MN, USA
| | - Anu Gupta
- US Medical Affairs, Pfizer Inc., New York, NY, USA
| | - Oluwaseyi Dina
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Lien Vo
- US Health Economics and Outcomes Research, Bristol-Myers Squibb, Lawrenceville, NJ, USA
| | - Patrick Hlavacek
- US Health Economics and Outcomes Research Pfizer Inc., New York, NY, USA,
| | - Lisa Rosenblatt
- US Medical Affairs, Bristol-Myers Squibb, Lawrenceville, NJ, USA
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Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018; 24:301S-313S. [PMID: 30428693 PMCID: PMC6714833 DOI: 10.1177/1076029618811082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.
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Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Sofia Butt
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
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Effect of rivaroxaban on preventing deep vein thrombosis in aged diabetics with femoral neck fractures after hip replacement. Biosci Rep 2017; 37:BSR20170289. [PMID: 28442600 PMCID: PMC5479017 DOI: 10.1042/bsr20170289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 11/17/2022] Open
Abstract
The present study estimates the effect of rivaroxaban on preventing deep vein thrombosis (DVT) in aged diabetics with femoral neck fractures after hip replacement. Our study consisted of 236 aged diabetics with femoral neck fractures, which were divided into the rivaroxaban and control groups. Reaction time (R time), clot formation time (K time), α angle (α), maximum amplitude (MA), clot elasticity (G) and coagulation index (CI), prothrombin time (PT) and activated partial thromboplastin time (APTT) were measured. DVT was diagnosed by color duplex Doppler ultrasound (CDDU). The risk factors of DVT were analysed by logistic regression analysis. Compared with the control group, in the rivaroxaban group, R time and K time were extended and α, MA and G decreased 1 day before operation. One day after operation, the rivaroxaban group had less PT and APPT and lower incidence of DVT than the control group. In the two groups, preoperative and postoperative PT and APPT significantly differed. Body mass index (BMI) ≥25, abnormal coagulation indicators, use of cemented femoral hip prosthesis, high haemoglobin content and non-ankle pump exercise after operation were the risk factors for DVT. Rivaroxaban could prevent DVT in aged diabetics with femoral neck fractures after hip replacement.
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Stein PD, Matta F, Hughes PG, Hourmouzis ZN, Hourmouzis NP, White RM, Ghiardi MM, Schwartz MA, Moore HL, Bach JA, Schweiss RE, Kazan VM, Kakish EJ, Keyes DC, Hughes MJ. Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants. Am J Med 2016; 129:974-7. [PMID: 27107921 DOI: 10.1016/j.amjmed.2016.03.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants. METHODS This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014. RESULTS Pulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known. CONCLUSION Even in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.
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Affiliation(s)
- Paul D Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| | - Patrick G Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Medical Education, Summa Akron City Hospital, Ohio; Department of Emergency Medicine, McLaren Oakland Hospital, Pontiac, Mich
| | - Zak N Hourmouzis
- Department of Medical Education, Summa Akron City Hospital, Ohio
| | | | - Rachel M White
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, Sparrow Health System, Lansing, Mich
| | - Martina M Ghiardi
- Department of Emergency Medicine, McLaren Oakland Hospital, Pontiac, Mich
| | - Matthew A Schwartz
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Hillary L Moore
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Jennifer A Bach
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Robert E Schweiss
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Viviane M Kazan
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Edward J Kakish
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Daniel C Keyes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, Sparrow Health System, Lansing, Mich
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Stein PD, Matta F, Hughes MJ. Home Treatment of Deep Venous Thrombosis According to Comorbid Conditions. Am J Med 2016; 129:392-7. [PMID: 26551984 DOI: 10.1016/j.amjmed.2015.10.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cautious exploration of the safety of home treatment of deep venous thrombosis has been recommended by many. Our goal was to identify categories of patients with deep venous thrombosis who typically are hospitalized, and categories frequently treated at home. METHODS The Nationwide Emergency Department Sample and the Nationwide Inpatient Sample, 2007-2012, were used to determine the number of patients seen in emergency departments throughout the US with deep venous thrombosis and no diagnosis of pulmonary embolism, the proportion of such patients hospitalized according to comorbid conditions and age, the proportion discharged early (≤2 days), and charges for hospitalization and emergency department visits. RESULTS From 2007-2012, home treatment was selected for 905,152 of 2,671,452 (33.9%) patients with deep venous thrombosis. Home treatment was more frequent in those with no comorbid conditions than with comorbid conditions, 58.0% compared with 15.5% (P <.0001). Early discharge (≤2 days) was in 23.9% with no comorbid conditions, compared with 12.8% with comorbid conditions. Among patients aged 18-50 years, home treatment was selected in 62.9% with no comorbid conditions, compared with 24.2% with comorbid conditions (P <.0001). Among hospitalized patients with no comorbid conditions, 40.7% were aged 18-50 years. Their charges for hospitalization in 2012 were $494 million. CONCLUSION Patients aged 50 years or younger with deep venous thrombosis and no comorbid conditions appear to be a group that can be targeted for more frequent home treatment, which would save millions of dollars.
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Affiliation(s)
- Paul D Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
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