Implementation of an acute DVT ambulatory care pathway in a large urban centre: current challenges and future opportunities

Diagnosis and Treatment of Deep Vein Thrombosis in the Emergency Department: Results of an Italian Nominal Group Technique Study

Early diagnosis and treatment of deep vein thrombosis (DVT) is a main issue in the Emergency setting. With the aim of assisting clinicians in the diagnosis and the subsequent management of DVT in the Emergency Departments, a Nominal Group Technique (NGT) study was conducted. A panel of 5 Italian experts developed 21 consensus statements based on available evidence and their clinical experience. The agreed consensus statements may assist clinicians in applying the results of clinical studies and clinical experience to routine care settings, providing guidance on all aspects of the risk assessment, prophylaxis, early diagnosis and appropriate treatment of DVT in the EDs.

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial

BACKGROUND

The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.

METHODS

This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.

RESULTS

We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.

CONCLUSIONS

Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.

Reducing emergency department visits in patients with deep vein thrombosis: introducing a standardised outpatient treatment pathway

Deep vein thrombosis (DVT) is an acute medical condition that requires urgent diagnosis and treatment to prevent significant morbidity and mortality. Patients with DVT frequently present to the emergency department (ED) because the necessary diagnostic investigations and medical treatment for successful outpatient management are not readily accessible in the outpatient clinics. A collaborative quality improvement project was undertaken to implement and evaluate a standardised outpatient treatment pathway designed to direct patients with a newly diagnosed DVT from the ultrasound department to the thrombosis clinic, where guideline-based management for DVT can be accomplished without ED visits. During the baseline period (1 February 2017 to 31 January 2019), the number of ED visits for DVT was 383 with an average of 16 visits per month. During the intervention period (1 February 2019 to 31 January 2020), the number of ED visits for DVT was 106 with an average of 8.8 visits per month. This represents almost a 50% reduction in the average ED visits during the intervention period. A standardised outpatient treatment pathway can significantly reduce the number of ED visits in patients with DVT, potentially improving patient care and reducing ED overcrowding.

Comparison of inpatient admission rates of patients treated with apixaban vs. warfarin for venous thromboembolism in the emergency department

Objectives: This study evaluated inpatient admission status, hospitalization length of stay (LOS), hospital costs, and readmissions of patients who were diagnosed with venous thromboembolism (VTE) and treated with apixaban or warfarin in the emergency department (ED).Methods: Patients (≥18 years) with an ED visit with a primary discharge diagnosis code of VTE were identified from the Premier Hospital database (8/1/2014-5/31/2018). Patients who received apixaban or warfarin during the ED visit were selected and grouped into two treatment cohorts. Outcomes of ED disposition (discharged or admitted to the inpatient setting), hospital LOS, hospital cost of index event, and rate of 1-month readmissions were compared for the study cohorts.Results: Of the overall study population, 30.5% (n = 12,174; mean age: 59.7 years) received apixaban and 69.5% (n = 27,767; mean age: 59.3 years) received warfarin for VTE in the ED. After adjusting for patient and hospital characteristics, the regression analysis showed that apixaban was associated with a significantly lower likelihood of admission to the inpatient setting vs. warfarin (Odds Ratio [OR]: 0.12, 95% Confidence Interval [CI]: 0.12 to 0.13; p < 0.001). Correspondingly, mean index hospital LOS was 1.42 days shorter (95% CI: -1.47 to -1.36; p < 0.001) and mean index event hospital cost per patient was significantly lower by $4,276 ($3,732 [95% CI: $3,565 to $3,907] vs. $8,008 [95% CI: $7,676 to $8,355]; p < 0.001). Also, the likelihood of all-cause 1-month readmission was significantly lower for patients treated with apixaban vs. warfarin (OR: 0.85, 95% CI: 0.79 to 0.92; p < 0.001).Conclusions: In the real-world setting, VTE patients with an ED visit who were treated with apixaban vs. warfarin had a lower likelihood of being admitted to the inpatient setting, which was reflected in shorter average LOS and lower average index event cost. Additionally, the risk of 1-month readmission was also lower for patients treated with apixaban vs. warfarin.