Prevalence and economic burden of pulmonary embolism in Germany

An overview of systematic reviews on imaging tests for diagnosis of pulmonary embolism applying different network meta-analytic methods

PURPOSE

This study aimed to apply different methods of diagnostic test accuracy network meta-analysis (DTA-NMA) for studies reporting results of five imaging tests for the diagnosis of suspected pulmonary embolism (PE): pulmonary angiography (PA), computed tomography angiography (CTPA), magnetic resonance angiography (MRA), planar ventilation/perfusion (V/Q) scintigraphy and single-photon emission computed tomography ventilation/perfusion (SPECT V/Q).

METHODS

We searched four databases (MEDLINE [via PubMed], Cochrane CENTRAL, Scopus, and Epistemonikos) from inception until June 2, 2022 to identify systematic reviews (SRs) describing diagnostic accuracy of PA, CTPA, MRA, V/Q scan and SPECT V/Q for suspected PE. Study-level data were extracted and pooled using a hierarchical summary receiver operating characteristic (HSROC) meta-regression approach and two DTA-NMA models to compare accuracy estimates of different imaging tests. Risk of bias was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

RESULTS

We identified 13 SRs, synthesizing data from 33 primary studies and for four imaging tests (PA, CTPA, MRA and V/Q scan). The HSROC meta-regression model using PA as the reference standard showed that MRA had the best overall diagnostic performance with sensitivity of 0.93 (95% confidence interval [CI]: 0.76, 1.00) and specificity of 0.94 (95% CI: 0.84, 0.99). However, DTA-NMA models indicated that V/Q scan had the highest sensitivity, while CTPA was most specific.

CONCLUSION

Selecting a different DTA-NMA method to assess multiple diagnostic tests can affect estimates of diagnostic accuracy. There is no established method, but the choice depends on the data and familiarity with Bayesian statistics.

Endovascular Venous Interventions - A State-of-the-Art Review

Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.

Clinical and Economic Outcomes of Intravenous Brivaracetam Compared With Levetiracetam for the Treatment of Seizures in United States Hospitals

Background: Seizures are common among hospitalized patients. Levetiracetam (LEV), a synaptic vesicle protein 2A (SV2A) ligand, is a common intravenous (IV) anti-seizure medication option in hospitals. Brivaracetam (BRV), a selective SV2A ligand for treatment of focal seizures in patients ≥16 years, has greater binding affinity, higher lipophilicity, and faster brain entry than IV LEV. Differences in clinical outcomes and associated costs between IV BRV and IV LEV in treating hospitalized patients with seizure remain unknown.

Objectives: To compare the clinical outcomes, costs, and healthcare resource utilization between patients with seizure treated with IV BRV and those with IV LEV within hospital setting.

Design/Methods: A retrospective cohort analysis was performed using chargemaster data from 210 United States hospitals in Premier Healthcare Database. Adult patients (age ≥18 years) treated intravenously with LEV or BRV (with or without BZD) and a seizure discharge diagnosis between July 1, 2016 and December 31, 2019 were included. The cohorts were propensity score-matched 4:1 on baseline characteristics. Outcomes included intubation rates, intensive care unit (ICU) admission, length of stay (LOS), all-cause and seizure-related readmission, total hospitalization cost, and in-hospital mortality. A multivariable regression analysis was performed to determine the association between treatment and main outcomes adjusting for unbalanced confounders.

Results: A total of 450 patients were analyzed (IV LEV, n = 360 vs. IV BRV, n = 90). Patients treated with IV BRV had lower crude prevalence of ICU admission (14.4 vs. 24.2%, P < 0.05), 30-day all-cause readmission (1.1 vs. 6.4%, P = 0.06), seizure-related 30-day readmission (0 vs. 4.2%, P < 0.05), similar mean total hospitalization costs ($13,715 vs. $13,419, P = 0.91), intubation (0 vs. 1.1%, P = 0.59), and in-hospital mortality (4.4 vs. 3.9%, P = 0.77). The adjusted odds for ICU admission (adjusted odds ratio [_aOR] = 0.6; 95% confidence interval [CI]:0.31, 1.16; P = 0.13), 30-day all-cause readmission (_aOR = 0.17; 95% CI:0.02, 1.24; P = 0.08), and in-hospital mortality (_aOR = 1.15; 95% CI:0.37, 3.58, P = 0.81) were statistically similar between comparison groups.

Conclusion: The use of IV BRV may provide an alternative to IV LEV for management of seizures in hospital setting due to lower or comparable prevalence of ICU admission, intubation, and 30-day seizure-related readmission. Additional studies with greater statistical power are needed to confirm these findings.

[Trends in mortality related to pulmonary embolism in the DACH countries]

Hintergrund

Kürzlich veröffentliche Studien zeigen eine steigende Inzidenz für die Lungenarterienembolie (LE) bei gleichzeitigem Rückgangs der LE-assoziierten Mortalität.

Ziel der Studie

Detaillierte Daten zur Mortalität der LE in Deutschland, Österreich und der Schweiz (DACH-Region) sind derzeit nicht vorhanden.

Material und Methoden

Datensätze wurden aus der Mortalitätsdatenbank der Weltgesundheitsorganisation (WHO) ausgewertet. Hierbei analysierten wir die Häufigkeit sowohl der akuten LE als auch der tiefen/oberflächlichen Venenthrombose als primärer Todesursache.

Ergebnisse

Demnach sank die jährliche altersstandardisierte Mortalität zwischen Januar 2000 und Dezember 2015 von 15,6 auf 7,8 Todesfälle pro 1000 Einwohner. Zwischen Januar 2012 und Dezember 2016 ereigneten sich in der DACH-Region (Bevölkerungsanzahl: 98.273.320 Menschen) durchschnittlich 9127 durch LE verursache Todesfälle pro Jahr. Interessanterweise ist LE–assoziierte Gesamtmortalität bei Frauen zwischen dem 15. und 55. Lebensjahr deutlich höher als bei gleichaltrigen Männern.

Schlussfolgerung

Der Rückgang der Mortalität durch die Erkrankung LE seit dem Jahr 2000 ist vermutlich durch eine verbesserte Patientenversorgung mit Einführung neuer Antikoagulanzien und durch den vermehrten Einsatz und diagnostischen Fortschritt bei den computertomographischen Untersuchungen erklärt. Festzuhalten ist, dass die LE eine wichtige Todesursache vor allem im höheren Alter darstellt. Außerdem ist der Anteil der Frauen im gebärfähigen Alter, die nach einer akuten LE sterben, mit 3,5 % hoch. Daher sind, trotz des medizinischen Fortschritts, weitere Anstrengungen für eine Verbesserung der Prävention, Diagnostik und Therapie, aber insbesondere auch des Krankheitsbewusstseins notwendig.

Systematic review and meta-analysis of test accuracy for the diagnosis of suspected pulmonary embolism

Pulmonary embolism (PE) is a common, potentially life-threatening yet treatable condition. Prompt diagnosis and expeditious therapeutic intervention is of paramount importance for optimal patient management. Our objective was to systematically review the accuracy of D-dimer assay, compression ultrasonography (CUS), computed tomography pulmonary angiography (CTPA), and ventilation-perfusion (V/Q) scanning for the diagnosis of suspected first and recurrent PE. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. 2 investigators screened and abstracted data. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 61 studies. The pooled estimates for D-dimer sensitivity and specificity were 0.97 (95% confidence interval [CI], 0.96-0.98) and 0.41 (95% CI, 0.36-0.46) respectively, whereas CTPA sensitivity and specificity were 0.94 (95% CI, 0.89-0.97) and 0.98 (95% CI, 0.97-0.99), respectively, and CUS sensitivity and specificity were 0.49 (95% CI, 0.31-0.66) and 0.96 (95% CI, 0.95-0.98), respectively. Three variations of pooled estimates for sensitivity and specificity of V/Q scan were carried out, based on interpretation of test results. D-dimer had the highest sensitivity when compared with imaging. CTPA and V/Q scans (high probability scan as a positive and low/non-diagnostic/normal scan as negative) both had the highest specificity. This systematic review was registered on PROSPERO as CRD42018084669.

The Refeeding Syndrome revisited: you can only diagnose what you know

BACKGROUND/OBJECTIVES

The Refeeding Syndrome (RFS) is a serious complication in patients receiving nutrition support after a period of severe malnutrition. We frequently recognize and diagnose the RFS due to increased awareness. Thus, we observe that many physicians do not know the RFS and that it is rarely diagnosed. The aim of the study was to determine whether physicians in Germany know the RFS.

SUBJECTS/METHODS

A questionnaire with a case vignette about an older person who developed the RFS after initiation of nutritional therapy was submitted to German physicians and fifth year medical students, who were participants of educational lectures.

RESULTS

Of the 281 participants who answered the respective question, 40 participants (14%) correctly diagnosed the RFS of the case vignette and 21 participants (8%) gave nearly correct answers. Indeed, the majority of the participants did not diagnose the RFS.

CONCLUSIONS

Although the RFS may lead to fatal complications, it is unknown to the majority of the queried physicians. Therefore, there is a call to implement the RFS in respective curricula and increase systematic education on this topic.

Pulmonary embolism in Europe - Burden of illness in relationship to healthcare resource utilization and return to work

OBJECTIVES

Pulmonary embolism (PE) is associated with a substantial economic burden. However evidence from patients in Europe is scarce. The aim of this study was to report the impacts of PE on healthcare resource utilization (HCRU) and return to work using the PREFER in VTE registry.

METHODS

The PREFER in VTE registry was a prospective, observational, multicenter study in seven European countries, aiming to provide data concerning treatment patterns, HCRU, mortality, quality of life and work-loss. Patients with a first-time or recurrent PE were included and followed up at 1, 3, 6 and 12 months. Treatment patterns, re-hospitalization rates, length of hospital stays (LOS), and ambulatory/office visits, as well as proportion of patients returning to work, were assessed. Subgroups by country and with/without active cancer were examined separately. Zero-inflated negative binomial and Cox regression were applied to investigate the relationship between baseline characteristics and LOS and return to work, respectively.

RESULTS

Amongst 1399 patients with PE, 53.2% were male and the average age was 62.3 ± 17.1 years old. Overall, patients were treated with combinations of heparin, vitamin K antagonists (VKA) and the non-VKA oral anticoagulants (NOACs) (50.0% treated with the combination of heparin with VKA). Patients with active cancer were primarily treated with heparin (84.9%). NOACs were used more frequently in DACH (Germany, Austria and Switzerland) and France (55.2% and 32.6%) compared to Italy and Spain (4.5% and 6.1%). The VTE-related re-hospitalization rate within 12 months and the average LOS varied substantially between countries, from 26.2% in UK to 12.3% in France, and from 12.9 days in Italy to 3.9 days in France. PE patients were often co-managed by general practitioners in France and DACH (>84%), and less frequently in other countries (<47%). The regression results confirmed the country variation of HCRU. Of the employed patients (n = 385), 60% returned to work at 1 month but 27.8% had not after one year. PE patients with DVT were more likely to return to work. Active cancer was a significant predictor for not returning to work, as well as smoking history.

CONCLUSIONS

Medical treatment of PE differed between patients with active cancer and patients without active cancer. VTE-related resource utilization differed markedly between countries. While the reported 'not return to work' was high for patients with PE, this may at least in part reflect the presence of co-morbidities such as cancer.

Trends in the use of echocardiography in pulmonary embolism

Pulmonary embolism (PE) is a devastating diagnosis which carries a high mortality risk. Echocardiography is often performed to risk stratify patients diagnosed with PE, and guide management strategies. Trends in the performance of echocardiography among patients with PE and its role in influencing outcomes is unknown.We analyzed the 2005 to 2014 National Inpatient Sample Database to identify patients with primary diagnosis of PE or secondary diagnosis of PE and ≥1 of the following diagnoses: syncope, thrombolysis, acute deep vein thrombosis, acute cardiorespiratory failure, and secondary pulmonary hypertension. Trends in the performance of echocardiography and in-hospital mortality were analyzed. The admissions were divided into 2 groups with echocardiography, and without echocardiography, and 1:2 propensity score matching (PSM) was performed for comparison. The primary end-point was in-hospital mortality. The secondary endpoints were length of stay and total hospitalization costs. Odd ratios (OR) with confidence intervals (CI) were reported.A total of 299,536 unweighted PE cases were studied. Performance of echocardiography among patients with PE patients increased from 3.5% to 5.6%, whereas in-hospital mortality decreased from 4.2% to 3.7% between years 2005 and 2014. Before matching, patients who received an echocardiogram were more likely to be younger, African American, admitted to a large, urban teaching institute, and had higher rates of concurrent acute deep vein thrombosis, and acute respiratory failure. Post-PSM, patients who received echocardiography during hospitalization had lower in-hospital mortality (odds ratio 0.75, 95% confidence intervals (CI) 0.68-0.83; P < 0.001), longer length of stay (median 6 days vs 5 days; P < .001) and higher mean hospitalization costs ($34,379 vs $27,803; P < .001) compared to those without echocardiography.Performance of echocardiography among patients with a PE is increasing and is associated with lower in-hospital mortality.

Acute and chronic pulmonary embolism: the role of the pulmonary embolism response team

PURPOSE OF REVIEW

Acute pulmonary embolism is a life-threatening condition that can lead to both acute and long-term morbidity and mortality. Patients with acute pulmonary embolism are at risk for significant complications including the development of chronic pulmonary embolism and chronic thromboembolic pulmonary hypertension. This review will describe the rationale for and structure of pulmonary embolism response teams, with a focus on the recognition and treatment of patients with persistent morbidity following pulmonary embolism.

RECENT FINDINGS

For patients with intermediate and high-risk pulmonary embolism, a myriad of treatment options exist, ranging from anticoagulation alone to surgical embolectomy and hemodynamic support with extracorporeal membrane oxygenation. Optimizing treatment for these patients requires rapid assessment and multidisciplinary cooperation. Over the last five years, the pulmonary embolism response team has emerged as a mechanism to facilitate this care.

SUMMARY

Pulmonary embolism response teams can streamline and expedite care for patients with intermediate and high-risk pulmonary embolism. However, the care for patients with acute pulmonary embolism does not end at hospital discharge. It is essential to ensure adequate follow-up and identify patients with persistent symptoms and impaired quality of life, particularly those who may have symptomatic chronic pulmonary embolism or chronic thromboembolic pulmonary hypertension.

European Union-28: An annualised cost-of-illness model for venous thromboembolism

Annual costs for venous thromboembolism (VTE) have been defined within the United States (US) demonstrating a large opportunity for cost savings. Costs for the European Union-28 (EU-28) have never been defined. A literature search was conducted to evaluate EU-28 cost sources. Median costs were defined for each cost input and costs were inflated to 2014 Euros (€) in the study country and adjusted for Purchasing Power Parity between EU countries. Adjusted costs were used to populate previously published cost-models based on adult incidence-based events. In the base model, annual expenditures for total, hospital-associated, preventable, and indirect costs were €1.5–2.2 billion, €1.0–1.5 billion, €0.5–1.1 billion and €0.2–0.3 billion, respectively (indirect costs: 12 % of expenditures). In the long-term attack rate model, total, hospital-associated, preventable, and indirect costs were €1.8–3.3 billion, €1.2–2.4 billion, €0.6–1.8 billion and €0.2–0.7 billion (indirect costs: 13 % of expenditures). In the multiway sensitivity analysis, annual expenditures for total, hospital-associated, preventable, and indirect costs were €3.0–8.5 billion, €2.2–6.2 billion, €1.1–4.6 billion and €0.5–1.4 billion (indirect costs: 22 % of expenditures). When the value of a premature life-lost increased slightly, aggregate costs rose considerably since these costs are higher than the direct medical costs. When evaluating the models aggregately for costs, the results suggests total, hospital-associated, preventable, and indirect costs ranging from €1.5–13.2 billion, €1.0–9.7 billion, €0.5–7.3 billion and €0.2–6.1 billion, respectively. Our study demonstrates that VTE costs have a large financial impact upon the EU-28’s healthcare systems and that significant savings could be realised if better preventive measures are applied.

Epidemiological trend of pulmonary thromboembolism at a tertiary hospital in Korea

BACKGROUND/AIMS

Despite increasing interest in pulmonary thromboembolism (PTE), data on recent trends in PTE incidence are limited. This study evaluated the recent incidence rate of PTE.

METHODS

We performed a retrospective chart review of patients with PTE admitted to Chung-Ang University Hospital during the 10-year period from 2006 to 2015. Age-standardized incidence and mortality rates were calculated by the direct method per 100,000 populations. To analyze the trend of risk factor, we also calculated the proportions of cancer, major operation, and recent major fracture over that time.

RESULTS

Total crude incidence rate of PTE per 100,000 was 229.36 and the age-sex adjusted standardized incidence rate was 151.28 (95% confidence interval [CI], 127.88 to 177.10). The incidence rate have been significantly increased 1.083 times annually from 2006 (105.96 per 100,000) to 2015 (320.02 per 100,000) (95% CI, 1.049 to 1.118; p < 0.001). These incidences also increased annually in age group of 35 to 54, 55 to 74, and ≥ 75 years, and in both males (odds ratio [OR], 1.071; 95% CI, 1.019 to 1.127; p = 0.007) and females (OR, 1.091; 95% CI, 1.047 to 1.136; p < 0.001). Cancer accounted for most of the increase from 20.0% at 2006 to 2007 to 42.8% at 2014 to 2015 (OR, 1.154; 95% CI, 1.074 to 1.240; p < 0.001), while the proportions of recent fracture and major operation remained constant.

CONCLUSIONS

The incidence of pulmonary embolism has gradually increased over the 10 years. The increase of PTE incidence was mainly due to increased proportion of cancer patients.

Association of impaired renal function with venous thrombosis: A genetic risk score approach

OBJECTIVE

The association between impaired kidney function and venous thrombosis has been previously reported but supportive data are still sparse. We here wish to strengthen this association by investigating, by use of a genetic risk score approach, whether single nucleotide polymorphisms (SNPs) known to decrease the estimated glomerular filtration rate (eGFR), a surrogate marker for renal dysfunction, are associated with increased risk of venous thrombosis.

APPROACH AND RESULTS

Fifty-one polymorphisms selected from the literature to robustly associate with eGFR were first tested for association with venous thrombosis in a French case-control collection of 1953 patients and 2338 healthy individuals. This led to the identification of a genetic risk score based on 9 polymorphisms that strongly associated with increased risk (odds ratio (OR)=1.09 [1.06-1.15], p=1.44·10^-7). This genetic score association replicated (OR=1.18 [1.11-1.26], p=8.86·10^-8) in an independent sample of 1289 patients and 1049 healthy controls part of the Dutch MEGA study. We then categorized the genetic score distribution observed in the combined samples into quintiles. Compared with the lowest quintile, the OR for increased risk of disease associated with the second, third, fourth and fifth quintiles were 1.13 [0.94-1.16], 1.47 [1.22-1.77], 1.52 [1.26-1.82] and 1.70 [1.41-2.05], respectively.

CONCLUSIONS

Using a genetic risk score analysis, our study provides new elements supporting the association between impaired renal function and the risk of venous thrombosis.

Factors Influencing Hospital Stay for Pulmonary Embolism. A Cohort Study

INTRODUCTION

The aim of this study was to identify factors influencing hospital stay due to pulmonary embolism.

METHODS

We performed a retrospective cohort study of patients hospitalized between 2010 and 2015. Patients were identified using information recorded in hospital discharge reports (ICD-9-CM codes 415.11 and 415.19).

RESULTS

We included 965 patients with a median stay of 8 days (IQR 6-13 days). Higher scores on the simplified Pulmonary Embolism Severity Index (sPESI) were associated with increased probability of longer hospital stay. The probability of a hospital stay longer than the median was 8.65 (95% CI 5.42-13.79) for patients referred to the Internal Medicine Department and 1.54 (95% CI 1.07-2.24) for patients hospitalized in other departments, compared to those referred to the Pneumology Department. Patients with grade 3 on the modified Medical Research Council dyspnea scale had an odds ratio of 1.63 (95% CI: 1.07-2.49). The likelihood of a longer than median hospital stay was 1.72 (95% CI: 0.85-3.48) when oral anticoagulation (OAC) was initiated 2-3 days after admission, and 2.43 (95% CI: 1.16-5.07) when initiated at 4-5 days, compared to OAC initiation at 0-1 days.

CONCLUSIONS

sPESI grade, the department of referral from the Emergency Department, the grade of dyspnea and the time of initiating OAC were associated with a longer hospital stay.

Weight-based contrast administration in the computerized tomography evaluation of acute pulmonary embolism: Challenges in optimizing imaging quality

Compare individualized contrast protocol, or weight-based protocol, to standard methodology in evaluating acute pulmonary embolism.Retrospective chart review was performed on patients undergoing computed tomography angiography with standard contrast protocol (n = 50) or individualized protocol (n = 50). Computerized tomography images were assessed for vascular enhancement and image quality.Demographics were comparable, however, more patients in the individualized group were admitted to intensive care unit (48% vs 16%, P = 0.004). Vascular enhancement and image quality were also comparable, although individualized protocol had significantly fewer contrast and motion artifact limitations (28% vs 48%, P = 0.039). Fifteen percent decrease in intravenous contrast volume was identified in individualized group with no compromise in image quality.Individualized contrast protocol provided comparable vascular enhancement and image quality to the standard, yet with fewer limitations and lower intravenous contrast volume. Catheter-gauge flow rate restrictions resulting in inconsistent technologist exam execution were identified, supporting the need for further investigation of this regimen.

Treatment of Venous Thromboembolism With New Anticoagulant Agents

Venous thromboembolism (VTE) is a common disease associated with high risk for recurrences, death, and late sequelae, accounting for substantial health care costs. Anticoagulant agents are the mainstay of treatment for deep vein thrombosis and pulmonary embolism. The recent availability of oral anticoagulant agents that can be administered in fixed doses, without laboratory monitoring and dose adjustment, is a landmark change in the treatment of VTE. In Phase III trials, rivaroxaban, apixaban, edoxaban (antifactor Xa agents), and dabigatran (an antithrombin agent) were noninferior and probably safer than conventional anticoagulation therapy (low-molecular-weight heparin followed by vitamin K antagonists). These favorable results were confirmed in specific patient subgroups, such as the elderly and fragile. However, some patients, such as those with cancer or with intermediate- to high-risk pulmonary embolism, were underrepresented in the Phase III trials. Further clinical research is required before new oral anticoagulant agents can be considered standard of care for the full spectrum of patients with VTE.

Developments in the management and treatment of pulmonary embolism

Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended.

Review of the cost of venous thromboembolism

Background

Venous thromboembolism (VTE) is the second most common medical complication and a cause of excess length of hospital stay. Its incidence and economic burden are expected to increase as the population ages. We reviewed the recent literature to provide updated cost estimates on VTE management.

Methods

Literature search strategies were performed in PubMed, Embase, Cochrane Collaboration, Health Economic Evaluations Database, EconLit, and International Pharmaceutical Abstracts from 2003–2014. Additional studies were identified through searching bibliographies of related publications.

Results

Eighteen studies were identified and are summarized in this review; of these, 13 reported data from the USA, four from Europe, and one from Canada. Three main cost estimations were identified: cost per VTE hospitalization or per VTE readmission; cost for VTE management, usually reported annually or during a specific period; and annual all-cause costs in patients with VTE, which included the treatment of complications and comorbidities. Cost estimates per VTE hospitalization were generally similar across the US studies, with a trend toward an increase over time. Cost per pulmonary embolism hospitalization increased from $5,198–$6,928 in 2000 to $8,764 in 2010. Readmission for recurrent VTE was generally more costly than the initial index event admission. Annual health plan payments for services related to VTE also increased from $10,804–$16,644 during the 1998–2004 period to an estimated average of $15,123 for a VTE event from 2008 to 2011. Lower costs for VTE hospitalizations and annualized all-cause costs were estimated in European countries and Canada.

Conclusion

Costs for VTE treatment are considerable and increasing faster than general inflation for medical care services, with hospitalization costs being the primary cost driver. Readmissions for VTE are generally more costly than the initial VTE admission. Further studies evaluating the economic impact of new treatment options such as the non-vitamin K antagonist oral anticoagulants on VTE treatment are warranted.

Acute pulmonary embolism: risk assessment, risk stratification and treatment options

INTRODUCTION

Pulmonary embolism (PE) is a potentially life-threatening cardiovascular emergency with a high mortality rate. Rapid diagnosis and treatment are important in optimising clinical outcomes in patients with PE, and anticoagulants are the mainstay of treatment. Traditionally, anticoagulant therapy involves parenteral anticoagulants, overlapping with and followed by oral vitamin K antagonists. Direct oral anticoagulants (DOACs), including the factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran etexilate, have been developed to address limitations associated with traditional anticoagulant therapy. Apixaban, dabigatran and rivaroxaban have recently been approved for the treatment of acute deep vein thrombosis (DVT) and PE and prevention of recurrent DVT or PE. Edoxaban is approved in the United States but not currently in the European Union for the treatment of DVT and PE; approval of edoxaban in Europe is anticipated in the near future.

OBJECTIVE

To summarise the management of patients with suspected PE in accordance with recent guidelines, and to discuss the evidence behind the recent approvals of the DOACs for the treatment of PE.

DISCUSSION

Diagnosis and treatment of PE is guided by clinical probability scoring systems and tools for prognostic stratification and early mortality risk evaluation. Anticoagulants remain the mainstay of treatment. Successful phase III trials have demonstrated the efficacy of the DOACs for the treatment of DVT and PE, with a potentially improved safety profile, leading to their recent approval in this indication, and giving the clinician greater choice of anticoagulant therapies in this setting.

CONCLUSIONS

DOACs offer an alternative and potentially simplified option for anticoagulation therapy in patients with PE compared with traditional anticoagulants and are likely to assist physicians in optimising management of patients with PE and improve clinical outcomes.

Trends in hospital admissions for pulmonary embolism in Spain from 2002 to 2011

The aim of our study was to analyse changes in the incidence, diagnostic procedures, comorbidity, length of hospital stay, costs and in-hospital mortality of patients hospitalised for pulmonary embolism in Spain over a 10-year period.

We included all patients who were hospitalised for pulmonary embolism (ICD-9-CM codes 415.11 and 415.19) as the primary diagnosis between 2002 and 2011. Data were collected from the National Hospital Discharge Database, covering the entire Spanish population.

115 671 patients were admitted. The overall crude incidence increased from 20.44 per 100 000 inhabitants in 2002 to 32.69 in 2011 (p<0.05). In 2002, 13.3% of patients had a Charlson comorbidity index >2, and in 2011 the prevalence increased to 20.8% (p<0.05). Mean length of hospital stay was 12.7 days in 2002 and decreased to 9.99 in 2011 (p<0.05). During the study period, mean cost per patient increased from €3915 to €4372 (p<0.05). In-hospital mortality decreased from 12.9% in 2002 to 8.32% in 2011 (p<0.05). The increase in the use of computed tomographic pulmonary angiography over time was associated with increased incidence and lower mortality.

Our results revealed an increase in the incidence of hospitalised pulmonary embolism patients from 2002 to 2011 with concomitant increase in comorbidities and cost. However, length of hospital stay and in-hospital mortality decreased.

Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial

BACKGROUND

When used with standard diagnostic testing, point-of-care ultrasonography might improve the proportion of patients admitted with respiratory symptoms who are correctly diagnosed 4 h after admission to the emergency department. We therefore assessed point-of-care ultrasonography of the heart, lungs, and deep veins in addition to the usual initial diagnostic testing in this patient population.

METHODS

In a prospective, parallel-group trial in the emergency department at Odense University Hospital, Odense, Denmark, patients (≥18 years) with a respiratory rate of more than 20 per min, oxygen saturation of less than 95%, oxygen therapy, dyspnoea, cough, or chest pain were randomly assigned in a 1:1 ratio with a computer-generated list to a standard diagnostic strategy (control group) or to standard diagnostic tests supplemented with point-of-care ultrasonography of the heart, lungs, and deep veins (point-of-care ultrasonography group). The primary endpoint was the percentage of patients with a correct presumptive diagnosis 4 h after admission to the emergency department. Only the physicians doing the primary clinical assessment and the auditors were masked. Analyses were by intention to treat. The study is registered with ClinicalTrials.gov, number NCT01486394.

FINDINGS

Between Dec 7, 2011, and March 15, 2013, 320 patients were randomly assigned to the control group (n=160) and point-of-care ultrasonography group (n=160). 158 patients in the point-of-care ultrasonography group and 157 in the control group were analysed. 4 h after admission to the emergency department, 139 patients (88·0%; 95% CI 82·8-93·1) in the point-of-care ultrasonography group versus 100 (63·7%; 56·1-71·3) in the control group had correct presumptive diagnoses (p<0·0001). The absolute and relative effects were 24·3% (95% CI 15·0-33·1) and 1·38 (1·01-1·31), respectively. No adverse events were reported.

INTERPRETATION

Point-of-care ultrasonography is a feasible, radiation free, diagnostic test, which alongside standard diagnostic tests is superior to standard diagnostic tests alone for establishing a correct diagnosis within 4 h. It should therefore be considered for routine use as part of the standard diagnostic tests in the emergency department for patients admitted with respiratory symptoms.

FUNDING

University of Southern Denmark, Odense University Hospital, and Højbjerg Fund.

Treatment of patients with acute deep vein thrombosis and/or pulmonary embolism: efficacy and safety of non-VKA oral anticoagulants in selected populations

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), presents a large clinical burden. Prompt, effective and sustained anticoagulation is vital because of the risk of recurrent events, including life-threatening PE, and complications such as post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Dual-drug standard therapy is effective; however, parenteral low molecular weight heparin, coupled with routine coagulation monitoring and dose adjustment of vitamin K antagonists (VKAs), presents challenges for patients and healthcare providers. Non-VKA oral anticoagulants provide a simplified option for VTE treatment. Phase III studies have investigated rivaroxaban and apixaban as single-drug approaches, and edoxaban and dabigatran in conjunction with initial heparin therapy. These agents demonstrated non-inferiority to standard therapy, and most showed significant reductions in major bleeding. However, clinical information is limited in patient subgroups, e.g. fragile patients or patients with renal impairment or cancer, who may be at higher risk of bleeding and/or VTE. A prespecified pooled analysis of the EINSTEIN DVT and EINSTEIN PE studies (8281 patients), undertaken to evaluate clinical outcomes with rivaroxaban versus standard therapy, confirmed the non-inferiority of rivaroxaban, with significant reductions in major bleeding and fewer intracranial and retroperitoneal bleeding events. Consistent efficacy and safety were observed with rivaroxaban, irrespective of fragility, cancer or clot severity. The introduction of the non-VKA oral anticoagulants and approval of rivaroxaban in the EU, US and Canada for the treatment and secondary prevention of DVT and PE offer the potential for improvements in effective care across a broad spectrum of patients with VTE.