Impact of thromboprophylaxis across the US acute care setting

Formal and informal venous thromboembolism risk assessment and impact on prescribing of thromboprophylaxis: a retrospective cohort study

BACKGROUND

Hospital-acquired thrombosis (HAT) is a leading cause of preventable death and disability worldwide. HAT includes any venous thromboembolic (VTE) event occurring in-hospital or within 90-days of hospitalisation. Despite availability of evidence-based guidelines for HAT risk assessment and prophylaxis, guidelines are still underutilised.

AIM

To determine the proportion of patients who developed HAT that could have been potentially prevented with appropriate VTE risk assessment and prophylaxis at a large public hospital in New Zealand. Additionally, the predictors of VTE risk assessment and thromboprophylaxis were examined.

METHOD

VTE patients admitted under general medicine, reablement, general surgery, or orthopaedic surgery service were identified using ICD-10-AM codes. Data were collected on patient characteristics, VTE risk factors, and the thromboprophylaxis regimen prescribed. The hospital VTE guidelines were used to determine rates of VTE risk assessment and the appropriateness of thromboprophylaxis.

RESULTS

Of 1302 VTE patients, 213 HATs were identified. Of these, 116 (54%) received VTE risk assessment, and 98 (46%) received thromboprophylaxis. Patients who received VTE risk assessment were 15 times more likely to receive thromboprophylaxis (odds ratio [OR] = 15.4; 95% CI 7.65-30.98) and 2.8 times more likely to receive appropriate thromboprophylaxis (OR = 2.79; 95% CI 1.59-4.89).

CONCLUSION

A large proportion of high-risk patients who were admitted to medical, general surgery and reablement services and who developed HAT did not receive VTE risk assessment and thromboprophylaxis during their index admission, demonstrating a significant gap between guideline recommendations and clinical practice. Implementing mandatory VTE risk assessment and adherence to guidelines to improve thromboprophylaxis prescription in hospitalised patients may help reduce the burden of HAT.

Assessment of Healthcare Resource Utilization by Anticoagulant Heparinoid Dosage Level in Patients Hospitalized with COVID-19

The aim was to describe inpatients with COVID-19 empirically prescribed heparinoid anticoagulants and compare resource utilization between prophylactic/low-dose and therapeutic/high-dose groups. Methods: This retrospective observational study used real-world data from 880 US hospitals in the PINC AI™ Healthcare Database during 4/1/2020–11/30/2020. Descriptive analysis was used to characterize patients. Multivariable regression was used to evaluate intensive care unit (ICU) admissions, length of stay (LOS), mortality, and costs by anticoagulation dose group, adjusting for cohort characteristics. Among 122,508 inpatients, 29,225 (23.9%) received therapeutic/high-dose, and 93,283 (76.1%) received prophylactic/low-dose anticoagulation. The high-dose group had more comorbidities and worse laboratory values compared with low-dose. Respectively, ICU admission rates were 36.7% and 19.1% and LOS median (Q1, Q3) was 8 (5, 15) and 5 (3, 9) days. In separate adjusted models, high-dose anticoagulation was associated with a 45% increase in odds of ICU admission, 26% increase in odds of in-hospital mortality, 21% longer average LOS, and 28% greater average total cost compared with low-dose (each P < 0.001). Prophylactic/low-dose anticoagulation treatment was associated with decreased healthcare resource utilization (HRU) in hospitalized patients with COVID-19.

Inappropriate prescription of low molecular weight heparins for thromboprophylaxis among older hospitalized patients

AIM

To investigate the prevalence and clinical correlates of overprescribing and underprescribing of low molecular weight heparins (LMWHs) for thromboprophylaxis among older medical inpatients.

METHODS

Eight hundred seventy six patients (mean age 81.5 ± 7.6 years, female gender 57.2 %) enrolled in a multicenter observational study of seven acute care wards of geriatric medicine in Italy. The risk of venous thromboembolism was ascertained by calculating the Padua score for each patient. Patients receiving appropriate prescription of LMHW during stay were compared to those receiving LMHW with a Padua score <4 (overprescribing group). Similarly, patients with a high thromboembolic risk (Padua score ≥4) but not receiving LMHW (underprescribing group) were compared to patients appropriately not receiving LMHW during stay. Independent correlates of overprescribing and underprescribing were investigated by logistic regression analysis.

RESULTS

Overall, 42.8 % of patients had a Padua score ≥4. LMWHs were overprescribed in 7.3 % and underprescribed in 25.2 % of patients. The number of lost basic activities of daily living (BADL) (OR = 0.25; 95 % CI 0.15-0.41) and the number of diagnoses (OR = 0.76; 95 % CI 0.61-0.95) were inversely associated with LMWH overprescription. Conversely, older age (75-84 years: OR = 2.39; 95 % CI 1.10-5.19-85 years or more: OR = 3.25, 95 % CI 1.40-7.61), anemia (OR = 1.80, 95 % CI 1.05-3.16), pressure sores (OR = 4.15, 95 % CI 1.20-14.3), number of lost BADL at the admission (OR = 3.92, 95 % CI 2.86-5.37) and number of diagnoses (OR = 1.29, 95 % CI 1.15-1.44) qualified as significant correlates of LMWH underprescription.

DISCUSSION

Underprescription and, to a lesser extent, overprescription still represent an issue among older medical inpatients.

CONCLUSION

Implementing risk-stratifying scores into clinical practice may improve appropriateness of LMWHs prescribing during hospitalization.

Exploring indications for the Use of direct oral anticoagulants and the associated risks of major bleeding

Thrombosis is a leading cause of morbidity and mortality in the United States. Arterial and venous thromboses are implicated in the pathogenesis of major disorders, including myocardial infarction, ischemic stroke, and venous thromboembolism. Over the past decade, direct oral anticoagulants (DOACs) (eg, direct thrombin inhibitor and factor Xa [FXa] inhibitors) have been adopted as alternatives to warfarin due to their clinical advantages and efficacy for the treatment of thrombosis. As with all anticoagulants, treatment with DOACs is associated with a risk of major bleeding, including life-threatening gastrointestinal bleeds and intracranial hemorrhages (ICHs). In turn, the burden of bleeding associated with DOAC treatment is itself associated with substantial healthcare costs that are amplified by an increased risk of thromboembolic events and mortality following major bleeding events, especially in patients with ICHs. Given the rapid adoption of the DOACs and projected usage in the large patient population affected by thromboembolic conditions, clinicians are increasingly likely to encounter patients with major bleeding events due to DOAC therapy. Unlike warfarin, effective strategies to manage these bleeds are limited. There is an unmet need for reversal agents for use in the management of patients who receive FXa inhibitors and experience life-threatening bleeding or need emergency surgery. Andexanet alfa and ciraparantag are being evaluated as potential antidotes for both direct and indirect FXa inhibitors.

Management of venous thromboembolism in cancer patients: the economic burden of hospitalizations

PURPOSE

Venous thromboembolism (VTE) is one of the most frequent events associated with cancer, requiring hospitalization and generating additional healthcare costs. To date, no studies analyzing the additional costs resulting from VTE associated with cancer in France have been published. The objective of this study was to provide an estimation of the additional cost induced by VTE with cancer by analyzing hospital stays reported in the 2013 PMSI French Hospital Database ("Programme de Médicalisation des Systèmes d'Information", a national hospital administrative database) for four cancer types (breast, lung, hepatocellular carcinoma, and colon).

METHODS

The analysis is divided into three parts: a descriptive evaluation of hospitalizations for VTE with cancer, an analysis by severity level of diagnosis-related groups (DRG), and an estimation of the hospital costs based on the National Reference Costs (ENC). The French public ATIH ("Agence Technique de l'Information sur l'Hospitalisation", a national Agency for Data on Hospital Care) database was used. The critical approach of this study is based on analysis of the distribution of stays according to levels of severity of DRG.

RESULTS

A total of 14,251 hospitalizations were analyzed combining VTE and cancer. Hospitalizations of the two highest levels of severity (levels 3 and 4) for VTE with cancer represented 81.7 % of all hospitalizations in this population. Increased costs were seen for all four cancer types evaluated, with cost coefficients ranging from 1.34 to 2.01. For example, the average cost of lung cancer in cancer patients with VTE in the PMSI database was 7296 € versus 4647 € in the ATIH database. Cost coefficients were calculated, ranging from 1.34 in colon cancer, 1.50 for breast cancer, 1.57 in lung cancer, and 2.01 for hepatocellular carcinoma.

CONCLUSION

As discussed in the article, the current costs are high. Better physician adherence to clinical practice guidelines could potentially reduce these costs by lowering the number of recurrent VTE in patients with cancer.