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Yarahuan JK, Kisvarday S, Kim E, Yan AP, Nakamura MM, Jones SB, Hron JD. An Algorithm to Assess Guideline Concordance of Antibiotic Choice in Community-Acquired Pneumonia. Hosp Pediatr 2024; 14:137-145. [PMID: 38287897 PMCID: PMC10823186 DOI: 10.1542/hpeds.2023-007418] [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] [Indexed: 01/31/2024]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to develop and evaluate an algorithm to reduce the chart review burden of improvement efforts by automatically labeling antibiotic selection as either guideline-concordant or -discordant based on electronic health record data for patients with community-acquired pneumonia (CAP). METHODS We developed a 3-part algorithm using structured and unstructured data to assess adherence to an institutional CAP clinical practice guideline. The algorithm was applied to retrospective data for patients seen with CAP from 2017 to 2019 at a tertiary children's hospital. Performance metrics included positive predictive value (precision), sensitivity (recall), and F1 score (harmonized mean), with macro-weighted averages. Two physician reviewers independently assigned "actual" labels based on manual chart review. RESULTS Of 1345 patients with CAP, 893 were included in the training cohort and 452 in the validation cohort. Overall, the model correctly labeled 435 of 452 (96%) patients. Of the 286 patients who met guideline inclusion criteria, 193 (68%) were labeled as having received guideline-concordant antibiotics, 48 (17%) were labeled as likely in a scenario in which deviation from the clinical practice guideline was appropriate, and 45 (16%) were given the final label of "possibly discordant, needs review." The sensitivity was 0.96, the positive predictive value was 0.97, and the F1 was 0.96. CONCLUSIONS An automated algorithm that uses structured and unstructured electronic health record data can accurately assess the guideline concordance of antibiotic selection for CAP. This tool has the potential to improve the efficiency of improvement efforts by reducing the manual chart review needed for quality measurement.
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Affiliation(s)
- Julia K.W. Yarahuan
- />Department of Pediatrics, Divisions of General Pediatrics
- Department of Pediatrics, Emory University School of Medicine and Division of Hospital Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Adam P. Yan
- Hematology and Oncology
- Department of Pediatrics, The University of Toronto and Division of Hematology Oncology, The Hospital of Sick Children, Toronto, Ontario, Canada
| | | | - Sarah B. Jones
- Antimicrobial Stewardship Program
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
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Mavros MN, Johnson LA, Schootman M, Orcutt ST, Peng C, Martin BC. Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery. Ann Surg Oncol 2023; 30:5522-5531. [PMID: 37338748 PMCID: PMC10409669 DOI: 10.1245/s10434-023-13677-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/08/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined. METHODS This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding. RESULTS The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61). CONCLUSIONS The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.
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Affiliation(s)
- Michail N Mavros
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Lauren A Johnson
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mario Schootman
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sonia T Orcutt
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cheng Peng
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Shevell L, Ochs M, Schaefer J. Prophylactic Anticoagulation in Patients with Cancer: When and How? Curr Oncol Rep 2023; 25:201-209. [PMID: 36705880 DOI: 10.1007/s11912-023-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.
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Affiliation(s)
- Lauren Shevell
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeleine Ochs
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jordan Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Postoperative Thromboembolism According to the Type of Surgery: A Nationwide Study in the Republic of Korea. J Clin Med 2022; 11:jcm11061477. [PMID: 35329803 PMCID: PMC8948856 DOI: 10.3390/jcm11061477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022] Open
Abstract
Postoperative thromboembolism (TE) is a serious, but preventable, complication in surgical patients. Orthopedic surgery, neurosurgery, and vascular surgery are considered high risk for TE, and current guidelines recommend TE prophylaxis. However, insufficient data exist regarding TE risk in other general surgeries. This study identified the actual incidence and relative risk of postoperative TE in the real world, according to surgery type. Twenty-six surgeries between 1 December 2017 and 31 August 2019 were selected from the Health Insurance Review and Assessment Service database and analyzed for postoperative TE events. Among all patients, 2.17% had a TE event within 6 months of surgery and 0.75% had a TE event owing to anticoagulant treatment. The incidence of total TE events was the highest in total knee replacement (12.77%), hip replacement (11.46%), and spine surgery (5.98%). The incidence of TE with anticoagulant treatment was the highest in total knee replacement (7.40%), hip replacement (7.20%), and coronary artery bypass graft (CABG) surgery (3.81%). Hip replacement, total knee replacement, CABG surgery, spine surgery, and cardiac surgery except CABG surgery, showed relatively higher risks for total claimed venous TE. The relative risk of venous TE with anticoagulant treatment was the highest for hysterectomy, partial hepatectomy, hip replacement, cardiac surgery except CABG surgery, and total knee replacement. The relative risk of arterial TE was the highest for cardiac surgery, total knee replacement, and hip replacement. In the real world, the incidence of postoperative TE events from total knee replacement and those from hip replacement remain high, and some surgeries could have a relatively higher risk of TE than other surgeries. For patients undergoing these surgeries, studies to reduce the incidence of postoperative TE in clinical practice should be conducted.
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Abdullah O, Parashar D, Mustafa IJ, Young AM. Venous Thromboembolism Rate in Patients With Bladder Cancer According to the Type of Treatment: A Systematic Review. Cureus 2022; 14:e22945. [PMID: 35411272 PMCID: PMC8987908 DOI: 10.7759/cureus.22945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/12/2022] Open
Abstract
Bladder cancer (BC) is classified as a high-risk tumour type for venous thromboembolism (VTE). VTE presents an extra challenge in the management of patients with cancer, given the increase in morbidity and mortality on having both conditions. To summarise the contemporary evidence on the VTE rate in patients with BC according to the stage, type of anti-cancer treatment and highlight VTE rate in the UK and other countries. A systematic review was carried out, and an electronic search for publications between January 2000 and November 2021 was done. Studies recording VTE in BC patients were included, whilst paediatric patients, case reports, studies reporting on a mix of arterial and venous thrombosis, studies reporting DVT or PE only and recorded hospitalised VTE only were excluded. The rate of VTE, country of origin, risk factors and thromboprophylaxis duration for VTE in BC patients were identified. A total of 38 papers met the search criteria. All publications were original research papers (cohort studies). The overall VTE rate in patients with BC was estimated at 1.9% to 4.7%. For those patients undergoing cystectomy, the VTE rate ranged from 3% to 17.6%; however, the VTE rate in the metastatic stage of BC patients ranged from 3.1% to 5.1%. The rates of VTE in BC patients are high, further increased by interventions such as surgery and chemotherapy. Thromboprophylaxis measures should be optimised. This review highlighted the fact that the VTE rate in BC varies between studies due to the heterogeneity of risk factors reported.
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Affiliation(s)
- Omar Abdullah
- Warwick Medical School, University of Warwick, Coventry, GBR
| | - Deepak Parashar
- Warwick Medical School, University of Warwick, Coventry, GBR
| | - Israa J Mustafa
- Mosul Cancer Control Centre, Nineveh Health Directorate, Mosul, IRQ
| | - Annie M Young
- Warwick Medical School, University of Warwick, Coventry, GBR
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Quintana-Montejo N, Valentín-Vega N, Domínguez-Torres LC. Del papel a la práctica: adherencia a las guías de práctica clínica de tromboprofilaxis en pacientes quirúrgicos en Colombia. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v71n1.95003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
El desarrollo del tromboembolismo venoso (TEV) en pacientes quirúrgicos representa un serio problema de salud pública, pues aumenta las tasas de morbimortalidad y los costos asociados con la atención intrahospitalaria de esta población. No obstante lo anterior, y a pesar de que su efectividad ha sido demostrada, en Colombia las medidas profilácticas no son utilizadas de forma adecuada en estos pacientes. Una posible causa de esta situación es la pobre adherencia de los profesionales de la salud a las guías de práctica clínica (GPC) para la prevención del TEV. En este sentido, se han descrito varias aproximaciones metodológicas para lograr una adecuada implementación de la tromboprofilaxis al transformar los comportamientos de los médicos. Sin embargo, para lograr este propósito es necesario considerar de forma integral las barreras multifactoriales y las condiciones sociológicas que subyacen a este problema. Se sabe que una mejor adherencia a las GPC de profilaxis de TEV conduce a una mejor práctica clínica. Por lo tanto, el objetivo de este artículo es realizar un análisis reflexivo de las causas y posibles soluciones de la baja adherencia de los profesionales de la salud en Colombia a dichas guías.
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Kaida S, Miyake T, Murata S, Yamaguchi T, Tatsuta T, Murakami K, Okauchi H, Nishimura S, Ohta H, Tsuchihashi H, Kawasaki M, Takebayashi K, Shimizu T, Tani M. A Prospective Multicenter Observational Study of Venous Thromboembolism after Gastric Cancer Surgery (SHISA-1601). Eur Surg Res 2021; 62:10-17. [PMID: 33657552 DOI: 10.1159/000514309] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/30/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to clarify the frequency and risk factors of intercurrent venous thromboembolism (VTE) in patients undergoing major curative gastric cancer surgery. METHODS This prospective, multicenter, observational study included patients with gastric cancer who underwent radical gastrectomy at 5 hospitals between June 2016 and May 2018. Patients who were preoperatively administered anticoagulants were excluded. RESULTS A total of 126 patients were eligible to participate. VTE occurred within 9 days postoperatively in 5 cases (4.0%; 2 symptomatic and 3 asymptomatic). Postoperative day (POD) 1 plasma D-dimer and soluble fibrin (SF) levels were significantly higher in the VTE group than in the non-VTE group. Receiver-operating characteristic curve (ROC) analysis indicated a statistically significant ability of POD 1 D-dimer and SF levels to predict postoperative VTE development after gastrectomy; this finding was reflected by an area under the curve (AUC) of 0.97 (95% CI 0.92-1.0) and 0.87 (95% CI 0.74-1.0), respectively. Cutoff values of D-dimer (24.6 µg/mL) and SF (64.1 µg/mL) were determined. Intraoperative blood transfusion (odds ratio [OR] 7.86), POD 1 D-dimer ≥24.6 µg/mL (OR 17.35), and POD 1 SF ≥64.1 µg/mL (OR 19.5) were independent predictive factors for postoperative VTE (p < 0.05). CONCLUSION VTE occurred in 4.0% patients (1.6% symptomatic and 2.4% asymptomatic) after gastric cancer surgery; however, with an early diagnosis and anticoagulant therapy, no patients experienced progression. Careful observation of patients with a high risk for VTE, including intraoperative blood transfusion and high POD 1 D-dimer or SF levels, would contribute to the early detection of VTE.
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Affiliation(s)
- Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan,
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Satoshi Murata
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan.,Cancer Center, Shiga University of Medical Science Hospital, Otsu, Japan
| | | | - Takeshi Tatsuta
- Department of Surgery, Tesseikai Neurosurgical Hospital, Osaka, Japan
| | - Koichiro Murakami
- Department of Surgery, Tesseikai Neurosurgical Hospital, Osaka, Japan
| | | | | | - Hiroyuki Ohta
- Department of Surgery, Higashi Oumi General Medical Center, Higashi-Oumi, Japan
| | | | | | | | - Tomoharu Shimizu
- Department of Medical Safety, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
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Mlaver E, Lynde GC, Gallion C, Sweeney JF, Sharma J. Development of a Novel Preoperative Venous Thromboembolism Risk Assessment Model. Am Surg 2020; 86:1098-1105. [PMID: 32967431 DOI: 10.1177/0003134820943556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Standardization of preoperative venous thromboembolism (VTE) risk assessment remains challenging due to variation in risk assessment models (RAMs) and the cumbersome workflow addition that most RAMs represent. We aimed to develop a parsimonious RAM that is automatable and actionable within the preoperative workflow. METHODS We performed a case-controlled review of all 18 VTE cases reported over a 12-month period and 171 matched controls included in an institutional National Surgical Quality Improvement Project (NSQIP) data set. We examined the predictive value of the Caprini, Padua, and NSQIP RAMs. We identified the 5 most impactful risk factors in VTE development by contribution to the known RAMs. We compared the predictive ability of cancer, age, body mass index, black race, and American Society of Anesthesiologists Physical Status (ASA-PS) score, to the Caprini, Padua, and NSQIP RAMs for VTE outcomes. Finally, we evaluated concordance between each of the models. RESULTS The Caprini Score was found to be 88.9% sensitive and 32.7% specific using a threshold of 5. The Padua score was found to be 61.1% sensitive and 47.4% specific using a threshold of 4. The novel 5-factor RAM was found to be 94.4% sensitive and 38.0% specific using a threshold of 4. The Caprini and Padua models were discordant in 26% of patients. DISCUSSION Cumbersome manual data entry contributes to the ongoing challenge of standardized VTE risk assessment and prophylaxis. Universally documented information and patient demographics can be utilized to create clinical decision support tools that can improve the efficiency of perioperative workflow and improve the quality of care.
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Affiliation(s)
- Eli Mlaver
- 1371 Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Grant C Lynde
- 1371 Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - John F Sweeney
- 1371 Department of Surgery, Emory University, Atlanta, GA, USA
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Henke PK, Kahn SR, Pannucci CJ, Secemksy EA, Evans NS, Khorana AA, Creager MA, Pradhan AD. Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation 2020; 141:e914-e931. [PMID: 32375490 DOI: 10.1161/cir.0000000000000769] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.
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Yang M, Murphy PB, Allen L, Sela N, Govind S, Leslie K, Vogt K. Venous thromboembolism in emergency general surgery patients: a single-centre retrospective cohort study. Can J Surg 2020; 63:E80-E85. [PMID: 32103656 DOI: 10.1503/cjs.006318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background There is limited literature on the risk of venous thromboembolism (VTE) in emergency general surgery (EGS) patients. We undertook this study to identify the rate of symptomatic VTE for patients undergoing EGS operations. Methods We conducted a retrospective cohort study evaluating EGS patients who underwent operative intervention between March and December 2014. Data collected included patient demographics, type of procedure, risk of VTE, VTE prophylaxis, development of symptomatic VTE, and mortality. Results We included 767 patients in our analysis. The mean age was 53 ± 19.7 years, and 52.2% of patients were female. Eighteen patients (2.3%) experienced VTE in hospital and 12 (1.6%) experienced VTE after discharge. Only 66% of patients received appropriate VTE prophylaxis. High-risk patients had a higher VTE rate (7.4% v. 2.3%, p < 0.001) and higher mortality (17.6% v. 4.0%, p < 0.001) than lowto moderate-risk patients. Conclusion The risk of VTE in patients requiring EGS is significant and persists after hospital discharge. Further studies on quality improvement with VTE prophylaxis are warranted.
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Affiliation(s)
- Mei Yang
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Patrick B. Murphy
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Laura Allen
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Nathalie Sela
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Shaylan Govind
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Ken Leslie
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
| | - Kelly Vogt
- From the Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Yang, Murphy, Sela, Govind, Leslie, Vogt); and the London Health Sciences Centre, London, Ont. (Allen)
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Kanitra J, Holtrop J, Jawad A, Berri R. Extended duration chemoprophylaxis for venous thromboembolism following abdominopelvic oncologic surgery. J Thromb Thrombolysis 2019; 50:190-194. [PMID: 31786714 DOI: 10.1007/s11239-019-02002-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is the most common cause of 30-day morbidity in oncology patients following surgery due to their hypercoagulable state. To combat this, VTE prophylaxis with anticoagulation extending beyond hospital discharge, termed extended duration chemoprophylaxis (EDCP), has been proposed, with the most recent guidelines recommending 28 post-operative days of EDCP. However, the literature has demonstrated poor compliance to these recommendations. We extended the duration of EDCP to 28 days post hospital discharge, effectively creating a standard discharge prescription for all surgical oncology patients. Our aim is to assess our EDCP protocol on patient compliance and VTE rate following major oncologic resection. We performed a retrospective, single institution, cohort study that involved chart review and telephone survey on patients who underwent major open abdominopelvic oncologic resection. A total of 130 patients were included; 60 received EDCP and 68 did not. VTE rate for the EDCP cohort was 0% and 7.4% for the non-EDCP cohort (p = 0.04). 85% of patients were fully compliant with EDCP. No bleeding related complications with EDCP were identified. Our data is consistent with prior literature in demonstrating a lower VTE rate with EDCP without an increase in bleeding related complications and we have demonstrated that it is possible to achieve a high rate of patient compliance with EDCP.
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Affiliation(s)
- John Kanitra
- Department of Surgery, Ascension St. John Hospital and Medical Center, 22151 Moross Rd, Suite 212, Detroit, MI, 48236, USA
| | - John Holtrop
- Department of Surgery, Ascension St. John Hospital and Medical Center, 22151 Moross Rd, Suite 212, Detroit, MI, 48236, USA
| | - Ali Jawad
- Department of Surgery, Ascension St. John Hospital and Medical Center, 22151 Moross Rd, Suite 212, Detroit, MI, 48236, USA
| | - Richard Berri
- Department of Surgery, Ascension St. John Hospital and Medical Center, 22151 Moross Rd, Suite 212, Detroit, MI, 48236, USA.
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Extended thromboprophylaxis with low-molecular weight heparin (LMWH) following abdominopelvic cancer surgery. Am J Surg 2019; 218:537-550. [DOI: 10.1016/j.amjsurg.2018.11.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/23/2018] [Accepted: 11/29/2018] [Indexed: 11/19/2022]
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13
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Zipple M, Itenberg E. Improving adherence to recommended venous thromboembolic prophylaxis in abdominal and pelvic oncologic surgery. Surgery 2018; 164:900-904. [PMID: 30076024 DOI: 10.1016/j.surg.2018.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND We reviewed rates of adherence to the American College of Chest Physicians guidelines for venous thromboembolism prophylaxis in abdominal and pelvic oncologic surgery at our community hospital compared with rates statewide. METHODS We completed a retrospective review of adult patients undergoing abdominal or pelvic oncologic surgery from January 1, 2015 to December 31, 2016, compared with statewide data from the Michigan Surgical Quality Collaborative during the same period. Educational intervention included creation of hospital guidelines and presentations reviewing American College of Chest Physicians guidelines and hospital adherence rates. A short-term observation of extended-duration venous thromboembolism prophylaxis rates was completed after the intervention. RESULTS The rates of in-hospital venous thromboembolism prophylaxis (general surgery: 93.7%, n = 106; gynecology: 40.0%, n = 32) were comparable to statewide in-hospital prophylaxis rates (89.6% general surgery, 41.8% gynecology). Five patients (4.5%) were prescribed extended-duration prophylaxis, which was lower than statewide rates (20.3%). In comparison, there was a statistically significant improvement in the rate of extended prophylaxis in the 6 months following intervention to 23.6% (n = 5, P < .0005). CONCLUSION The rates of extended-duration venous thromboembolism prophylaxis prescription were lower than the state average at our community hospital; however, the short-term evaluation revealed significant improvement after intervention.
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Affiliation(s)
- Monica Zipple
- Department of Surgery, Saint Joseph Mercy Oakland, Pontiac, Michigan
| | - Edwin Itenberg
- Department of Surgery, Saint Joseph Mercy Oakland, Pontiac, Michigan.
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Kahn SR, Morrison DR, Diendéré G, Piché A, Filion KB, Klil‐Drori AJ, Douketis JD, Emed J, Roussin A, Tagalakis V, Morris M, Geerts W. Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database Syst Rev 2018; 4:CD008201. [PMID: 29687454 PMCID: PMC6747554 DOI: 10.1002/14651858.cd008201.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. While numerous randomized controlled trials (RCTs) have shown that the appropriate use of thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective, and cost-effective, thromboprophylaxis remains underused or inappropriately used. Our previous review suggested that system-wide interventions, such as education, alerts, and multifaceted interventions were more effective at improving the prescribing of thromboprophylaxis than relying on individual providers' behaviors. However, 47 of the 55 included studies in our previous review were observational in design. Thus, an update to our systematic review, focused on the higher level of evidence of RCTs only, was warranted. OBJECTIVES To assess the effects of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of VTE in hospitalized adult medical and surgical patients at risk for VTE, focusing on RCTs only. SEARCH METHODS Our research librarian conducted a systematic literature search of MEDLINE Ovid, and subsequently translated it to CENTRAL, PubMed, Embase Ovid, BIOSIS Previews Ovid, CINAHL, Web of Science, the Database of Abstracts of Reviews of Effects (DARE; in the Cochrane Library), NHS Economic Evaluation Database (EED; in the Cochrane Library), LILACS, and clinicaltrials.gov from inception to 7 January 2017. We also screened reference lists of relevant review articles. We identified 12,920 potentially relevant records. SELECTION CRITERIA We included all types of RCTs, with random or quasi-random methods of allocation of interventions, which either randomized individuals (e.g. parallel group, cross-over, or factorial design RCTs), or groups of individuals (cluster RCTs (CRTs)), which aimed to increase the use of prophylaxis or appropriate prophylaxis, or decrease the occurrence of VTE in hospitalized adult patients. We excluded observational studies, studies in which the intervention was simply distribution of published guidelines, and studies whose interventions were not clearly described. Studies could be in any language. DATA COLLECTION AND ANALYSIS We collected data on the following outcomes: the number of participants who received prophylaxis or appropriate prophylaxis (as defined by study authors), the occurrence of any VTE (symptomatic or asymptomatic), mortality, and safety outcomes, such as bleeding. We categorized the interventions into alerts (computer or human alerts), multifaceted interventions (combination of interventions that could include an alert component), educational interventions (e.g. grand rounds, courses), and preprinted orders (written predefined orders completed by the physician on paper or electronically). We meta-analyzed data across RCTs using a random-effects model. For CRTs, we pooled effect estimates (risk difference (RD) and risk ratio (RR), with 95% confidence interval (CI), adjusted for clustering, when possible. We pooled results if three or more trials were available for a particular intervention. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS From the 12,920 records identified by our search, we included 13 RCTs (N = 35,997 participants) in our qualitative analysis and 11 RCTs (N = 33,207 participants) in our meta-analyses. PRIMARY OUTCOME Alerts were associated with an increase in the proportion of participants who received prophylaxis (RD 21%, 95% CI 15% to 27%; three studies; 5057 participants; I² = 75%; low-certainty evidence). The substantial statistical heterogeneity may be in part explained by patient types, type of hospital, and type of alert. Subgroup analyses were not feasible due to the small number of studies included in the meta-analysis.Multifaceted interventions were associated with a small increase in the proportion of participants who received prophylaxis (cluster-adjusted RD 4%, 95% CI 2% to 6%; five studies; 9198 participants; I² = 0%; moderate-certainty evidence). Multifaceted interventions with an alert component were found to be more effective than multifaceted interventions that did not include an alert, although there were not enough studies to conduct a pooled analysis. SECONDARY OUTCOMES Alerts were associated with an increase in the proportion of participants who received appropriate prophylaxis (RD 16%, 95% CI 12% to 20%; three studies; 1820 participants; I² = 0; moderate-certainty evidence). Alerts were also associated with a reduction in the rate of symptomatic VTE at three months (RR 64%, 95% CI 47% to 86%; three studies; 5353 participants; I² = 15%; low-certainty evidence). Computer alerts were associated with a reduction in the rate of symptomatic VTE, although there were not enough studies to pool computer alerts and human alerts results separately. AUTHORS' CONCLUSIONS We reviewed RCTs that implemented a variety of system-wide strategies aimed at improving thromboprophylaxis in hospitalized patients. We found increased prescription of prophylaxis associated with alerts and multifaceted interventions, and increased prescription of appropriate prophylaxis associated with alerts. While multifaceted interventions were found to be less effective than alerts, a multifaceted intervention with an alert was more effective than one without an alert. Alerts, particularly computer alerts, were associated with a reduction in symptomatic VTE at three months, although there were not enough studies to pool computer alerts and human alerts results separately.Our analysis was underpowered to assess the effect on mortality and safety outcomes, such as bleeding.The incomplete reporting of relevant study design features did not allow complete assessment of the certainty of the evidence. However, the certainty of the evidence for improvement in outcomes was judged to be better than for our previous review (low- to moderate-certainty evidence, compared to very low-certainty evidence for most outcomes). The results of our updated review will help physicians, hospital administrators, and policy makers make practical decisions about adopting specific system-wide measures to improve prescription of thromboprophylaxis, and ultimately prevent VTE in hospitalized patients.
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Affiliation(s)
- Susan R Kahn
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDivision of Internal Medicine and Department of MedicineMontrealQCCanadaH3T 1E2
| | - David R Morrison
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - Gisèle Diendéré
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - Alexandre Piché
- McGill UniversityDepartment of Mathematics and StatisticsMontrealCanada
| | - Kristian B Filion
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDepartments of Medicine and of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Adi J Klil‐Drori
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - James D Douketis
- McMaster University and St. Josephs HospitalDepartment of MedicineRoom F‐53850 Carlton Avenue EastHamiltonONCanadaL8N 4A6
| | - Jessica Emed
- Jewish General HospitalDepartment of Nursing3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - André Roussin
- University of Montreal and Thrombosis CanadaDepartment of Medicine1851 Sherbrooke St # 601MontrealQCCanadaH2K 4LS
| | - Vicky Tagalakis
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDivision of Internal Medicine and Department of MedicineMontrealQCCanadaH3T 1E2
| | - Martin Morris
- McGill UniversitySchulich Library of Physical Sciences, Life Sciences and EngineeringMontrealCanada
| | - William Geerts
- Sunnybrook Health Sciences Centre, University of TorontoDepartment of MedicineRoom D674, 2075 Bayview AvenueTorontoONCanadaM4N 3M5
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15
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Cohen JG, Prendergast E, Geddings JE, Walts AE, Agadjanian H, Hisada Y, Karlan BY, Mackman N, Walsh CS. Evaluation of venous thrombosis and tissue factor in epithelial ovarian cancer. Gynecol Oncol 2017; 146:146-152. [PMID: 28501328 DOI: 10.1016/j.ygyno.2017.04.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/25/2017] [Accepted: 04/27/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Ovarian clear cell carcinoma (OCCC) and high grade serous ovarian cancer (HGSOC) are associated with the highest risk of VTE among patients with epithelial ovarian cancer (EOC). Tissue factor (TF) is a transmembrane glycoprotein which can trigger thrombosis. We sought to evaluate if there is an association between VTE and tumor expression of tissue factor (TF), plasma TF, and microvesicle TF (MV TF) activity in this high-risk population. METHODS We performed a case-control study of OCCC and HGSOC patients with and without VTE. 105 patients who underwent surgery at a tertiary care center between January 1995 and October 2013 were included. Plasma TF was measured with an enzyme-linked immunosorbent assay. A TF-dependent Factor Xa generation assay was used to measure MV TF activity. Immunohistochemical (IHC) analysis was performed to evaluate tumor expression of TF. RESULTS 35 women with OCCC or HGSOC diagnosed with VTE within 9months of surgery were included in the case group. Those with VTE had a worse OS, p<0.0001, with a greater than three-fold increase in risk of death, HR 3.33 (CI 1.75-6.35). There was no significant difference in median plasma TF level or MV TF activity level between patients with and without VTE. OCCC patients had greater expression of TF in their tumors than patients with HGSOC, p<0.0001. CONCLUSIONS TFMV activity and plasma TF level were not predictive of VTE in this patient population. Given the extensive expression of TF in OCCC tumors, it is unlikely IHC expression will be useful in risk stratification for VTE in this population.
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Affiliation(s)
- Joshua G Cohen
- Division of Gynecologic Oncology, University of California, Los Angeles, 200 Medical Plaza, Suite 220, Los Angeles, CA 90095, USA
| | - Emily Prendergast
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Julia E Geddings
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA
| | - Ann E Walts
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Hasmik Agadjanian
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Yohei Hisada
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA; K.G. Jebsen TREC, The Faculty of Health Sciences, UiT- The Arctic University of Tromsø, 9037 Tromsø, Norway
| | - Beth Y Karlan
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Nigel Mackman
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA; K.G. Jebsen TREC, The Faculty of Health Sciences, UiT- The Arctic University of Tromsø, 9037 Tromsø, Norway
| | - Christine S Walsh
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
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16
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Murad MH. Clinical Practice Guidelines: A Primer on Development and Dissemination. Mayo Clin Proc 2017; 92:423-433. [PMID: 28259229 DOI: 10.1016/j.mayocp.2017.01.001] [Citation(s) in RCA: 253] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/28/2016] [Accepted: 01/05/2017] [Indexed: 01/01/2023]
Abstract
Trustworthy clinical practice guidelines should be based on a systematic review of the literature, provide ratings of the quality of evidence and the strength of recommendations, consider patient values, and be developed by a multidisciplinary panel of experts. The quality of evidence reflects our certainty that the evidence warrants a particular action. Transforming evidence into a decision requires consideration of the quality of evidence, balance of benefits and harms, patients' values, available resources, feasibility of the intervention, acceptability by stakeholders, and effect on health equity. Empirical evidence shows that adherence to guidelines improves patient outcomes; however, adherence to guidelines is variable. Therefore, guidelines require active dissemination and innovative implementation strategies.
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Affiliation(s)
- M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, MN.
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