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Calonge Q, Le Gac F, Chavez M, Degremont A, Quantin C, Tubach F, du Montcel ST, Navarro V. Burden of status epilepticus: prognosis and cost driving factors, insight from a nationwide retrospective cohort study of the French health insurance database. J Neurol 2024; 271:6761-6772. [PMID: 39177750 DOI: 10.1007/s00415-024-12589-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Status epilepticus (SE) imposes a significant burden in terms of in-hospital mortality and costs, but the relationship between SE causes, patient comorbidities, mortality, and cost remains insufficiently understood. We determined the in-hospital mortality and cost-driving factors of SE using a large and comprehensive database. METHODS We conducted a retrospective cohort study involving patients experiencing their first hospitalization with an ICD-10 code diagnosis of SE, spanning from January 1, 2015, to December 31, 2019, using the French health insurance database which covers 99% of population. Patient characteristics, SE causes, Intensive Care Unit (ICU) admissions, mechanical ventilation, discharge status, and health insurance costs were extracted for each hospitalization. RESULTS We identified 52,487 patients hospitalized for a first SE. In-hospital mortality occurred in 11,464 patients (21.8%), with associated factors including age (Odds Ratio [OR], 10.3, 95% Confidence Interval [CI] 7.87-13.8 for ages over 80 compared to 10-19), acute causes (OR, 15.3, 95% CI 13.9-16.8 for hypoxic cause), tumors (OR, 1.75, 95% CI 1.63-1.8), comorbidities (OR, 3.00, 95% CI 2.79-3.24 for 3 or more comorbidities compared to 0), and prolonged mechanical ventilation (OR, 2.61, 95% CI 2.42-2.82). The median reimbursed cost for each SE hospitalization was 6517€ (3364-13,354), with cost factors mirroring those of in-hospital mortality. CONCLUSION Causes and co-morbidities are major determinants of mortality and hospital costs in status epilepticus, and factors associated with higher mortality are also often associated with higher costs. Further studies are needed to identify their long-term effects.
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Affiliation(s)
- Quentin Calonge
- Sorbonne Université, Paris Brain Institute-Institut du Cerveau, ICM, INSERM, CNRS, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, DMU Neurosciences, Paris, France
- AP-HP, Center of Reference for Rare Epilepsies, ERN EpiCare, Pitié-Salpêtrière Hospital, Paris, France
| | - François Le Gac
- Sorbonne Université, Paris Brain Institute-Institut du Cerveau, ICM, INSERM, CNRS, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Mario Chavez
- Sorbonne Université, Paris Brain Institute-Institut du Cerveau, ICM, INSERM, CNRS, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Adeline Degremont
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, CHU de Rennes, 35033, Rennes, France
- Univ Rennes, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, 35000, Rennes, France
| | - Catherine Quantin
- Service de Biostatistiques et d'Information Médicale (DIM), CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, 21000, Dijon, France
- Université Paris-Saclay, UVSQ, Inserm, CESP, 94807, Villejuif, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), 75013, Paris, France
| | - Sophie Tezenas du Montcel
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, CNRS, Inria, Inserm, AP HP, 75013, Paris, France
| | - Vincent Navarro
- Sorbonne Université, Paris Brain Institute-Institut du Cerveau, ICM, INSERM, CNRS, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
- AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, DMU Neurosciences, Paris, France.
- AP-HP, Center of Reference for Rare Epilepsies, ERN EpiCare, Pitié-Salpêtrière Hospital, Paris, France.
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Yap AJY, Teo DCH, Ang PS, Yap ES, Tan SH, Loke CWP, Dorajoo SR. Validation of a Major and Clinically Relevant Nonmajor Bleeding Phenotyping Algorithm on Electronic Health Records. Pharmacoepidemiol Drug Saf 2024; 33:e5875. [PMID: 39090800 DOI: 10.1002/pds.5875] [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: 11/27/2023] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE Bleeding is an important health outcome of interest in epidemiological studies. We aimed to develop and validate rule-based algorithms to identify (1) major bleeding and (2) all clinically relevant bleeding (CRB) (composite of major and all clinically relevant nonmajor bleeding) within real-world electronic healthcare data. METHODS We took a random sample (n = 1630) of inpatient admissions to Singapore public healthcare institutions in 2019 and 2020, stratifying by hospital and year. We included patients of all age groups, sex, and ethnicities. Presence of major bleeding and CRB were ascertained by two annotators through chart review. A total of 630 and 1000 records were used for algorithm development and validation, respectively. We formulated two algorithms: sensitivity- and positive predictive value (PPV)-optimized algorithms. A combination of hemoglobin test patterns and diagnosis codes were used in the final algorithms. RESULTS During validation, diagnosis codes alone yielded low sensitivities for major bleeding (0.16) and CRB (0.24), although specificities and PPV were high (>0.97). For major bleeding, the sensitivity-optimized algorithm had much higher sensitivity and negative predictive values (NPVs) (sensitivity = 0.94, NPV = 1.00), however false positive rates were also relatively high (specificity = 0.90, PPV = 0.34). PPV-optimized algorithm had improved specificity and PPV (specificity = 0.96, PPV = 0.52), with little reduction in sensitivity and NPV (sensitivity = 0.88, NPV = 0.99). For CRB events, our algorithms had lower sensitivities (0.50-0.56). CONCLUSIONS The use of diagnosis codes alone misses many genuine major bleeding events. We have developed major bleeding algorithms with high sensitivities, which can ascertain events within populations of interest.
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Affiliation(s)
- Aaron Jun Yi Yap
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Desmond Chun Hwee Teo
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Pei San Ang
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Siew Har Tan
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Celine Wei Ping Loke
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Sreemanee Raaj Dorajoo
- Vigilance & Compliance Branch, Health Products Regulation Group, Health Sciences Authority, Singapore
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Hernandez I, Yang L, Tang S, Cameron T, Guo J, Gabriel N, Essien UR, Magnani JW, Gellad WF. COVID-19 pandemic and trends in clinical outcomes and medication use for patients with established atrial fibrillation: A nationwide analysis of claims data. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100396. [PMID: 38689680 PMCID: PMC11059438 DOI: 10.1016/j.ahjo.2024.100396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
Study objective The COVID-19 pandemic disrupted multiple aspects of the health care system, including the diagnosis and control of chronic conditions. This study aimed to quantify pandemic-related changes in the rates of clinical events among patients with atrial fibrillation (AF). Design/setting/participants In this retrospective cohort study, we identified individuals with established AF at any time before 2019 using de-identified Optum's Clinformatics® Data Mart, and followed them from 3/18/2019 to death, or disenrollment, or the end of the study (09/30/2021). Main outcome Rates of clinical event, including all-cause hospitalization, ischemic stroke, and bleeding. We constructed interrupted time series to test changes in outcomes after the onset of the COVID-19 pandemic (3/11/2020, date of pandemic declaration). We then identified the first month after the start of the pandemic in which outcomes returned to pre-pandemic levels. Results A total of 561,758 patients, with a mean age of 77 ± 9.9 years, were included in the study. The monthly incidence rate of all-cause hospitalization decreased from 2.8 % in the period immediately before the pandemic declaration to 1.7 % in the period immediately after, with p-value for level change<0.001. The rate of new ischemic stroke diagnoses decreased from 0.28 % in the period immediately before pandemic declaration to 0.20 % in the period immediately after, and the rate of major bleeding diagnoses from 0.81 % to 0.59 %, both p-values for level change<0.01. The incidence rate of ischemic stroke and bleeding events returned to pre-pandemic levels in October and November 2020, respectively. Conclusions The COVID-19 pandemic was associated with a decrease in health care visits for ischemic stroke and bleeding in a nationwide cohort of patients with established AF.
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Affiliation(s)
- Inmaculada Hernandez
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, United States of America
| | - Lanting Yang
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, United States of America
| | - Shangbin Tang
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, United States of America
| | - Teresa Cameron
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, United States of America
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, United States of America
| | - Nico Gabriel
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, United States of America
| | - Utibe R. Essien
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States of America
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, United States of America
| | - Jared W. Magnani
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Walid F. Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System Pittsburgh, PA, United States of America
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Hwang YJ, Chang HY, Metkus T, Andersen KM, Singh S, Alexander GC, Mehta HB. Risk of Major Bleeding Associated with Concomitant Direct-Acting Oral Anticoagulant and Clopidogrel Use: A Retrospective Cohort Study. Drug Saf 2024; 47:251-260. [PMID: 38141156 PMCID: PMC10942724 DOI: 10.1007/s40264-023-01388-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND AIM Combined anticoagulant-antiplatelet therapy is often indicated in adults with cardiovascular disease and atrial fibrillation or venous thromboembolism. The study aim was to assess the comparative risk of bleeding between rivaroxaban and apixaban when combined with clopidogrel. METHODS We conducted a retrospective cohort study of commercially insured US adults newly treated with a combination of rivaroxaban+clopidogrel or apixaban+clopidogrel (2015-2018) using Merative™ Marketscan Research Databases. We used propensity score-based inverse probability of treatment weighting (IPTW) to balance the treatment groups. Weighted Cox proportional hazards regression was used to estimate the risk of major bleeding. RESULTS The study cohort included 2895 rivaroxaban+clopidogrel users and 3628 apixaban+clopidogrel users. The median (range) duration of follow up was 61 (73) days. Rivaroxaban+clopidogrel users had a similar risk of major bleeding compared with apixaban+clopidogrel users (IPTW incidence rate per 100 person-years 7.96 vs 7.38; IPTW hazard ratio [HR] 1.13 [95% CI 0.78-1.63]). In the subcohort of adults who were treated with DOAC or clopidogrel monotherapy prior to the combined therapy, the risk of major bleeding did not differ by the drug of monotherapy (IPTW HR for rivaroxaban+clopidogrel group: 0.66 [95% CI 0.33-1.32]; IPTW HR for apixaban+clopidogrel group: 1.10 [95% CI 0.55-2.23]) CONCLUSIONS: In our study of commercially insured US adults, the concomitant use of rivaroxaban+clopidogrel and apixaban+clopidogrel conferred a similar risk of major bleeding. DOAC versus clopidogrel monotherapy prior to the concomitant therapy did not influence the risk of major bleeding.
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Affiliation(s)
- Y Joseph Hwang
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA.
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Thomas Metkus
- Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen M Andersen
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonal Singh
- UMass Chan Medical School, Worcester, MA, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Lusk JB, Wilson L, Nalwade V, Song A, Schrag M, Biousse V, Li F, Poli S, Piccini J, Xian Y, O’Brien E, Mac Grory B. Atrial fibrillation as a novel risk factor for retinal stroke: A protocol for a population-based retrospective cohort study. PLoS One 2023; 18:e0296251. [PMID: 38157342 PMCID: PMC10756549 DOI: 10.1371/journal.pone.0296251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Central retinal artery occlusion (CRAO; retinal stroke or eye stroke) is an under-recognized, disabling form of acute ischemic stroke which causes severe visual loss in one eye. The classical risk factor for CRAO is ipsilateral carotid stenosis; however, nearly half of patients with CRAO do not have high-grade carotid stenosis, suggesting that other cardiovascular risk factors may exist for CRAO. Specifically, prior studies have suggested that cardioembolism, driven by underlying atrial fibrillation, may predispose patients to CRAO. We describe the design of an observational, population-based study in this protocol. We evaluate two specific objectives: 1) To determine if atrial fibrillation is an independent risk factor for CRAO after adjusting for medical and cardiovascular risk; 2) To determine if use of oral anticoagulation can modify the risk of CRAO for patients with atrial fibrillation. This protocol lays out our strategy for cohort definition, case and control definition, comorbidity ascertainment, and statistical methods.
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Affiliation(s)
- Jay B. Lusk
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke University Fuqua School of Business, Durham, North Carolina, United States of America
| | - Lauren Wilson
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
| | - Vinit Nalwade
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
| | - Ailin Song
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Durham, North Carolina, United States of America
| | - Valerie Biousse
- Department of Neurology, Emory University School of Medicine, Durham, North Carolina, United States of America
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Fan Li
- Department of Biostatistics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
| | - Jonathan Piccini
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ying Xian
- Department of Neurology, University of Texas- Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Population Health Sciences, University of Texas-Southwestern Medical Center, Dallas, Texas, United States of America
| | - Emily O’Brien
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States of America
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Galimzhanov A, Matetic A, Tenekecioglu E, Mamas MA. Prediction of clinical outcomes after percutaneous coronary intervention: Machine-learning analysis of the National Inpatient Sample. Int J Cardiol 2023; 392:131339. [PMID: 37678434 DOI: 10.1016/j.ijcard.2023.131339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/08/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND This study aimed to develop a multiclass machine-learning (ML) model to predict all-cause mortality, ischemic and hemorrhagic events in unselected hospitalized patients undergoing percutaneous coronary intervention (PCI). METHODS This retrospective study included 1,815,595 unselected weighted hospitalizations undergoing PCI from the National Inpatient Sample (2016-2019). Five most common ML algorithms (logistic regression, support vector machine (SVM), naive Bayes, random forest (RF), and extreme gradient boosting (XGBoost)) were trained and tested with 101 input features. The study endpoints were different combinations of all-cause mortality, ischemic cerebrovascular events (CVE) and major bleeding. An area under the curve (AUC) with 95% confidence interval (95% CI) was selected as a performance metric. RESULTS The study population was split to a training cohort of 1,186,880 PCI discharges, validation cohort (for calibration) of 296,725 hospitalizations and a test cohort of 331,990 PCI discharges. A total of 98,180 (5.4%) hospital entries included study outcomes. Logistic regression, SVM, naive Bayes, and RF model demonstrated AUCs of 0.83 (95% CI 0.82-0.84), 0.84 (95% CI 0.83-0.86), 0.81 (95% CI 0.80-0.82), and 0.83 (95% CI 0.81-0.84), retrospectively. The XGBoost classifier performed the best with an AUC of 0.86 (95% CI 0.85-0.87) with excellent calibration. We then built a web-based application that provides predictions based on the XGBoost model. CONCLUSION We derived the multi-task XGBoost classifier based on 101 features to predict different combinations of all-cause death, ischemic CVE and major bleeding. Such models may be useful in benchmarking and risk prediction using routinely collected administrative data.
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Affiliation(s)
- Akhmetzhan Galimzhanov
- Department of Propedeutics of Internal Disease, Semey Medical University, Semey, Kazakhstan; Keele Cardiovascular Research Group, Keele University, Keele, UK.
| | - Andrija Matetic
- Keele Cardiovascular Research Group, Keele University, Keele, UK; Department of Cardiology, University Hospital of Split, Split 21000, Croatia
| | - Erhan Tenekecioglu
- Department of Cardiology, Bursa Education and Research Hospital, Health Sciences University, Bursa,Turkey; Department of Cardiology, Thoraxcenter, Erasmus MC, Erasmus University, Rotterdam, the Netherlands
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
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Ferreira AS, Maux Lessa MP, Sanborn K, Kuchibhatla M, Karafin MS, Onwuemene OA. In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III. J Clin Apher 2023; 38:694-702. [PMID: 37548357 PMCID: PMC10841207 DOI: 10.1002/jca.22080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Major bleeding in patients undergoing therapeutic plasma exchange (TPE) has been studied in large databases; but without standardizing bleeding definitions. Therefore, we used standardized definitions to evaluate major bleeding in hospitalized patients undergoing TPE using public use data files from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). STUDY DESIGN AND METHODS In a retrospective cross-sectional analysis, we identified TPE-treated adults in a first inpatient encounter. We evaluated major bleeding prevalence using (1) International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, (2) packed red blood cell (PRBC) transfusion, or (3) hemoglobin (Hgb) decline. Patients with major bleeding prior to their first TPE were excluded from the analysis. RESULTS Among 779 patients undergoing TPE, major bleeding by at least one of the three bleeding definitions occurred in 135 patients (17.3%). For each of the ICD/CPT, PRBC, and Hgb definitions, the prevalence of major bleeding was 2.8% (n = 31), 7.4% (n = 81), and 5.4% (n = 59), respectively. Only 3.7% of bleeds (5/135) were captured by all three definitions and 19.3% (26/135) exclusively by any two pairwise definitions. The addition of PRBC transfusion and Hgb decline to ICD/CPT code definitions increased bleeding prevalence threefold. CONCLUSION Among hospitalized adults undergoing TPE in the REDS-III study, the prevalence of major bleeding was 17.3%. The addition of PRBC and Hgb decline to ICD codes increased bleeding prevalence threefold. Future studies are needed to develop validated models that identify patients at risk for major bleeding during TPE.
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Affiliation(s)
- Alexandre Soares Ferreira
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Kate Sanborn
- Duke Biostatistics, Epidemiology and Research Design Core, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Pang B, Kearney L, Maccarone J, Zhang J, Kearney C, Sangani R, Shankar DA, Gillmeyer KR, Law AC, Bosch NA. Association between Early Venous Thromboembolism Prophylaxis, Bleeding Risk, and Venous Thromboembolism among Critically Ill Patients with Thrombocytopenia. Ann Am Thorac Soc 2023; 20:917-920. [PMID: 36867519 PMCID: PMC10257036 DOI: 10.1513/annalsats.202210-847rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
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Clinical use of low-dose parenteral anticoagulation, incidence of major bleeding and mortality: a multi-centre cohort study using the French national health data system. Eur J Clin Pharmacol 2022; 78:1137-1144. [PMID: 35385975 DOI: 10.1007/s00228-022-03318-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Low-dose parenteral anticoagulation has demonstrated its efficacy for venous thromboembolism prophylaxis in randomized trials. However, current practice is not widely documented. In ambulatory settings, we aimed to provide an overview of the clinical use of low-dose parenteral anticoagulation in France and to assess the incidence of major bleeding and death rates. METHODS A population-based prospective cohort study using the French national health data system (SNIIRAM) identified 142,815 adults living in five well-defined geographical areas who had a course of low-dose parenteral anticoagulants (a total of 150,389 courses) in the period 2013-2015. The main outcome measures were the types of low-dose parenteral anticoagulant, the duration and the clinical context. Adjusted incidence rate ratios (IRR) were derived from Poisson models. RESULTS Enoxaparin was the most frequently prescribed anticoagulant (58.9%) followed by tinzaparin (27.3%) and fondaparinux (10.9%). Patients receiving unfractionated heparin (N = 766, 0.53%) were older, more frequently had renal disease (48.75%) and had a higher modified HAS-B(L)ED score (≥ 3 in 61.6%) than patients receiving low-molecular weight heparin (LMWH). Surgical thrombo-prophylaxis was the most frequent indication (47.6%), followed by medical prophylaxis (29.9%). Course durations were in line with regulatory agency specifications. Only 43 (0.028%) major bleeding events and 478 (0.32%) deaths were observed. Adjusted IRRs for major bleeding or death were not significantly different for dalteparin/nadroparin, tinzaparin or fondaparinux compared to enoxaparin. CONCLUSION Very low incidence rates of major bleeding and all-cause mortality were observed. Our study confirms the safety of LMWHs and fondaparinux in thrombo-prophylaxis in ambulatory settings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02886533.
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Gouda P, Dover DC, Savu A, Bainey K, Goodman SG, Welsh R, Kaul P, Sandhu RK. Long-Term Outcomes for Patients With Acute Coronary Syndrome and Nonvalvular Atrial Fibrillation. Am J Cardiol 2022; 167:54-61. [PMID: 35012753 DOI: 10.1016/j.amjcard.2021.11.043] [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] [Received: 09/24/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
Short-term outcomes are worse for patients with acute coronary syndrome (ACS) with a history of nonvalvular atrial fibrillation (NVAF). However, long-term prognosis remains unclear. We linked administrative health databases to identify patients hospitalized with ACS (ST-elevation myocardial infarction [STEMI], non-STEMI [NSTEMI], and unstable angina) between 2008 and 2019 in Alberta, Canada. Patients were stratified according to history of NVAF before hospitalization. The primary outcome was a composite of all-cause mortality, hospitalization for myocardial infarction, or stroke at 3 years. Cox models were constructed to estimate the association between ACS, NVAF, and outcomes. Of 54,309 ACS hospitalizations, 6,351 patients (11.7%) had a history of NVAF. Compared with patients without NVAF, patients with previous NVAF were older (75.6 ± 11.6 vs 64.9 ± 13.4 years), women (35.1% vs 30.0%), had higher comorbid burden (Charlson co-morbidity index 3.0 vs 1.0), and more often presented with NSTEMI (57.5% vs 49.0%). The primary outcome occurred in 37.0% of patients with previous NVAF and 17.4% without (p <0.001). In the multivariable analysis, there was a 1.14-fold (95% confidence interval [CI] 1.09 to 1.20) higher risk of the primary outcome in patients with previous NVAF. There was a significant association with STEMI (adjusted harazard ratio [aHR] 1.24, 95% CI 1.12 to 1.36) and NSTEMI (aHR 1.12, 95% CI 1.06 to 1.19) but not with unstable angina (aHR 1.04, 95% CI 0.90 to 1.22). In conclusion, in this population-based study, we identified that a history of NVAF at ACS presentation is associated with worse long-term prognosis, particularly for STEMI and NSTEMI.
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11
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Red Blood Cell Transfusion at a Hemoglobin Threshold of Seven g/dL in Critically Ill Patients: A Regression Discontinuity Study. Ann Am Thorac Soc 2022; 19:1177-1184. [PMID: 35119978 DOI: 10.1513/annalsats.202109-1078oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In critically ill patients, a hemoglobin transfusion threshold of <7.0 G/dl compared to <10.0 G/dl improves organ dysfunction. However, it is unclear if transfusion at a hemoglobin of <7.0 g/dL is superior to no transfusion. OBJECTIVES To compare levels of organ dysfunction between transfusion and no transfusion at a hemoglobin threshold of <7.0 G/dl among critically ill patients using quasi-experimental regression discontinuity methods. METHODS We performed regression discontinuity analysis using hemoglobin measurements from patients admitted to ICUs in three cohorts (MIMIC-IV, eICU, and Premier Inc.), estimating the change in organ dysfunction (modified sequential organ failure assessment score) in the 24-72-hour window following each hemoglobin measurement. We compared hemoglobin levels just above and below 7.0 g/dL using a 'fuzzy' discontinuity approach, based on the concept that measurement noise pseudorandomizes similar hemoglobin levels on either side of the transfusion threshold. RESULTS A total of 11,181, 13,664, and 167,142 patients were included in the MIMIC-IV, eICU, and Premier cohorts, respectively. Patient characteristics below the threshold did not differ from those above the threshold, except that crossing below the threshold resulted in a >20% absolute increase in transfusion rates in all three cohorts. Transfusion was associated with increases in hemoglobin level in the subsequent 24-72 hours (MIMIC-IV 2.4 [95% CI 1.1, 3.6] g/dL; eICU 0.7 [95% CI 0.3, 1.2] g/dL; Premier 1.9 [95% CI 1.5, 2.2] g/dL), but not with improvement in organ dysfunction (MIMIC-IV 4.6 [95% CI -1.2, 10] points; eICU 4.4 [95% CI 0.9, 7.8] points; Premier 1.1 [95% CI -0.2, 2.3] points), compared to no transfusion. CONCLUSIONS Transfusion was not associated with improved organ dysfunction compared to no transfusion at a hemoglobin threshold of 7.0 g/dL, suggesting that evaluation of transfusion targets other than a hemoglobin threshold of 7.0 G/dl may be warranted.
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12
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Benamouzig R, Guenoun M, Deutsch D, Fauchier L. Review Article: Gastrointestinal Bleeding Risk with Direct Oral Anticoagulants. Cardiovasc Drugs Ther 2021; 36:973-989. [PMID: 34143317 DOI: 10.1007/s10557-021-07211-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared with vitamin K antagonists (VKAs) remains controversial. Accordingly, we aimed to provide a focused overview of the risk of gastrointestinal bleeding associated with dabigatran, rivaroxaban, apixaban and edoxaban and its management. METHODS We reviewed published studies reporting on DOACs with gastrointestinal bleeding as an outcome, including randomised controlled trials (RCTs), retrospective database studies and large-scale prospective cohort studies. RESULTS Cumulative evidence confirms no notable difference in major gastrointestinal bleeding risk between DOACs and VKAs. Moreover, gastrointestinal bleeding in DOAC-treated patients seems less severe and requires less intensive management. The main cause of upper gastrointestinal bleeding in DOAC-treated patients appears to be gastroduodenal ulcers, whereas lower gastrointestinal bleedings are mainly due to diverticula followed by angiodysplasia and haemorrhoids. The lack of head-to-head RCTs with DOACs precludes drawing conclusions on the DOAC with the lowest gastrointestinal bleeding risk. Prescribing physicians should be aware of risk factors for DOAC-related gastrointestinal bleeding (e.g. age > 65, heavy alcohol use, uncontrolled hypertension, hepatic or renal dysfunction, active cancer, anaemia) and adopt preventive measures accordingly. Management of DOAC-associated major gastrointestinal bleeding involves temporary discontinuation of the DOAC, investigation of the bleeding source and treatment of bleeding with fluid resuscitation combined with transfusion and endoscopic haemostasis. CONCLUSION DOACs as a class do not increase the risk of major gastrointestinal bleeding compared to VKAs, which supports their continued use for different anticoagulant indications.
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Affiliation(s)
- Robert Benamouzig
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France.
| | - Maxime Guenoun
- Department of Cardiology, Clinique Bouchard, Marseille, France
| | - David Deutsch
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France
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13
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Das D, Savu A, Bainey KR, Welsh RC, Kaul P. Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population. CJC Open 2021; 3:479-487. [PMID: 34027351 PMCID: PMC8129449 DOI: 10.1016/j.cjco.2020.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population. Methods Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality. Results Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6). Conclusions The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes.
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Affiliation(s)
- Debraj Das
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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14
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Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
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Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
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15
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Osmont MN, Degremont A, Jantzem H, Audouard-Marzin Y, Lalanne S, Carlhant-Kowalski D, Bellissant E, Oger E, Polard E. Hospital databases for the identification of adverse drug reactions: A 2-year multicentre study in 9 French general hospitals. Br J Clin Pharmacol 2020; 87:471-482. [PMID: 32484575 DOI: 10.1111/bcp.14405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS To estimate the actual number of adverse drug reactions (ADRs), we used the French medical administrative database (PMSI) in addition to ADRs spontaneously reported in the French Pharmacovigilance Database (FPVDB). METHODS Capture-recapture method was applied to these 2 sources (PMSI and FPVDB), checking their independence via a third data source. The study ran from 1 July 2014 to 30 June 2016 in 9 French general hospitals. From PMSI, all discharge summaries including a selection of 10th International Classification of Diseases codes related to ADRs were analysed. This selection was based on the results of a previous study. All ADRs corresponding to these codes, spontaneously reported in the FPVDB, were included. RESULTS In PMSI, 56.9% of hospital stays were related to an ADR (628 out of 1104). In the FPVDB, we retained 115 cases. A total of 43 ADRs were common to the 2 databases. In both sources, the most frequently reported ADRs were cutaneous (33.1 and 19.1%) and renal (25.2% and 11.6%). The most frequently suspected drugs were anti-infectives in PMSI (31.1%) and antineoplastic drugs in the FPVDB (30.4%). Using the capture-recapture method, the estimated number of ADRs was 1657 [95% CI: 1273 to 2040]. CONCLUSION The use of the PMSI could constitute an additional tool for the estimation of the actual number of ADRs in French hospitals. A model involving a third data source enabled the independence of the 2 sources (PMSI and FPVDB) to be checked before applying the capture-recapture method.
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Affiliation(s)
- Marie-Noëlle Osmont
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France
| | - Adeline Degremont
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France.,Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Rennes, France
| | | | | | - Sébastien Lalanne
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France
| | | | - Eric Bellissant
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France.,Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Rennes, France
| | - Elisabeth Polard
- Pharmacovigilance and pharmacoepidemiology centre, Pharmacology Department, CHU, Rennes, France.,Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', Rennes, France
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16
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Althunian TA, de Boer A, Groenwold RHH, Rengerink KO, Souverein PC, Klungel OH. Rivaroxaban was found to be noninferior to warfarin in routine clinical care: A retrospective noninferiority cohort replication study. Pharmacoepidemiol Drug Saf 2020; 29:1263-1272. [PMID: 32537897 PMCID: PMC7687233 DOI: 10.1002/pds.5065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/28/2022]
Abstract
Purpose To compare the effectiveness and safety of a drug in daily practice with the outcomes of a target non‐inferiority trial by rigorously mimickingin an observational study the trial's design features. Methods This cohort study was conducted using the British Clinical Practice Research Datalink (CPRD) to emulate the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial. Patients with atrial fibrillation who were newly prescribed (>=12 months of no use) either rivaroxaban or warfarinfrom October 2008 to December 2017 were included. Non‐inferiority of rivaroxaban to warfarin in the prevention of stroke or systemic embolism was assessed in different analysis populations (intention‐to‐treat [ITT], per‐protocol [PP], and as‐treated populations) using a hazardratio (HR) of 1.46 as the non‐inferiority margin. Major bleeding (safety outcome) was also assessed and compared to that of the target trial. All outcomes were analyzed using Cox‐proportional hazard analyses. Results We included 25,473 incident users of rivaroxaban (n=4,008) or warfarin(n=21,465). Similar to the trial, non‐inferiority in the primary out come was demonstrated in all three analysis populations: HR=1.04 (95%CI 0.84 to 1.30) (ITT), HR=0.98 (95%CI 0.70 to 1.38) (PP), and HR=1.11 (95%CI 0.86 to 1.42) (as‐treated). Risk of major bleeding was also similar to the target trial. Conclusion The results of this study provide supportive evidence to the effectiveness of rivaroxaban and adds knowledge on the usefulness of emulating a non‐inferiority trial to assess drug effectiveness.
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Affiliation(s)
- Turki A Althunian
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Chairman of the Dutch Medicines Evaluation Board, Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Katrien O Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Bouget J, Balusson F, Maignan M, Pavageau L, Roy PM, Lacut K, Scailteux LM, Nowak E, Oger E. Major bleeding risk associated with oral anticoagulant in real clinical practice. A multicentre 3-year period population-based prospective cohort study. Br J Clin Pharmacol 2020; 86:2519-2529. [PMID: 32415705 DOI: 10.1111/bcp.14362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 04/21/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The objective was to compare major bleeding risk of direct oral anticoagulants (DOACs; per type and dose) with vitamin K antagonists (VKAs), irrespective of indication, using real-world data. METHODS A population-based prospective cohort study, using the French national health data system (SNIIRAM), identified 47 469 adults living within 5 well-defined geographical areas, who were new users of oral anticoagulants in the period 2013-2015: 20 205 VKA users, 19 579 rivaroxaban users, 4225 dabigatran users and 3460 apixaban users. From all emergency departments within these areas, clinical data for all adults referred for bleeding was collected and medically validated. The databases were linked for common key variables. The main outcome measure was major bleeding: intracranial haemorrhage, major gastrointestinal bleeding and other major bleeding events. Hazard ratios were derived from adjusted Cox proportional hazard models. We used propensity score weighting as a sensitivity analysis, with separate analyses according to indications (atrial fibrillation or venous thromboembolism). RESULTS Compared to VKAs, high and low-dose DOACs were associated with a reduced risk of intracranial haemorrhage (adjusted hazard ratio 0.55, 95% confidence interval 0.37-0.82 and 0.54, 0.26-1.12 respectively), and a reduced risk of other major bleeding events (0.41, 0.29-0.58 and 0.41, 0.22-0.79 respectively), irrespective of duration and indication. Neither DOAC dose evidenced any significant difference from VKAs in terms of risk of major gastrointestinal bleeding. CONCLUSION There is a clear benefit of using DOACs with regard to intracranial haemorrhage. The study provides new insight into major gastrointestinal and other major bleeding events.
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Affiliation(s)
- Jacques Bouget
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Frédéric Balusson
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Maxime Maignan
- Emergency Department, University Hospital, Grenoble, France
| | - Laure Pavageau
- Emergency Department, University hospital, Nantes, France
| | | | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Lucie-Marie Scailteux
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
| | - Emmanuel Nowak
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM, CHRU de Brest, Brest, France
| | - Emmanuel Oger
- Univ Rennes, CHU Rennes, EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Rennes, France
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