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Anzai Y, Delis K, Pendleton RC. Price Transparency in Radiology-A Model for the Future. J Am Coll Radiol 2021; 17:194-199. [PMID: 31918882 DOI: 10.1016/j.jacr.2019.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/11/2019] [Accepted: 08/12/2019] [Indexed: 10/25/2022]
Abstract
Medicine is the only business transaction in which consumers make important purchase decisions without knowing how much they have to pay. Lack of price transparency in health care imposes financial burden and anxiety among patients as the cost of health care has been shifting from employers to patients through high-deductible health plans (HDHPs). Health economists and policymakers anticipated that HDHPs with price transparency would be a catalyst for patients to "shop" for low-price providers, thus reducing overall health care spending. For patients to shop health care services, price transparency is a requisite. The Department of Health and Human Services mandate of publicly disclosing the hospital chargemaster and state legislatures demanding greater health care price transparency are just two examples of external forces challenging the long history of price opacity in health care. Imaging, pharmacy, laboratory tests, and ambulatory surgeries are considered potentially shoppable health care services. This article examines the intended motivation of price transparency, the limitations of current price transparency tools, and what impact price transparency may have on radiology. We share our experience in developing and implementing University of Utah's online interactive price transparency tool to estimate patients' out-of-pocket expenses.
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Affiliation(s)
- Yoshimi Anzai
- Department of Radiology & Imaging Sciences, University of Utah, Salt Lake City, Utah.
| | - Kathy Delis
- Revenue Cycle Support Services, University of Utah Health, Salt Lake City, Utah
| | - Robert C Pendleton
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Gage BF, Bass AR, Lin H, Woller SC, Stevens SM, Al-Hammadi N, Anderson JL, Li J, Rodriguez T, Miller JP, McMillin GA, Pendleton RC, Jaffer AK, King CR, Whipple B, Porche-Sorbet R, Napoli L, Merritt K, Thompson AM, Hyun G, Hollomon W, Barrack RL, Nunley RM, Moskowitz G, Dávila-Román V, Eby CS. Effect of Low-Intensity vs Standard-Intensity Warfarin Prophylaxis on Venous Thromboembolism or Death Among Patients Undergoing Hip or Knee Arthroplasty: A Randomized Clinical Trial. JAMA 2019; 322:834-842. [PMID: 31479138 PMCID: PMC6724181 DOI: 10.1001/jama.2019.12085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The optimal international normalized ratio (INR) to prevent venous thromboembolism (VTE) in warfarin-treated patients with recent arthroplasty is unknown. OBJECTIVE To determine the safety and efficacy of a target INR of 1.8 vs 2.5 for VTE prophylaxis after orthopedic surgery. DESIGN, SETTING, AND PARTICIPANTS The randomized Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis enrolled 1650 patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. INTERVENTIONS In a 2 × 2 factorial design, participants were randomized to a target INR of 1.8 (n = 823) or 2.5 (n = 827) and to either genotype-guided or clinically guided warfarin dosing. For the first 11 days of therapy, open-label warfarin dosing was guided by a web application. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of VTE (within 60 days) or death (within 30 days). Participants underwent screening duplex ultrasound postoperatively. The hypothesis was that an INR target of 1.8 would be noninferior to an INR target of 2.5, using a noninferiority margin of 3% for the absolute risk of VTE. Secondary end points were bleeding and INR values of 4 or more. RESULTS Among 1650 patients who were randomized (mean age, 72.1 years; 1049 women [63.6%]; 1502 white [91.0%]), 1597 (96.8%) received at least 1 dose of warfarin and were included in the primary analysis. The rate of the primary composite outcome of VTE or death was 5.1% (41 of 804) in the low-intensity-warfarin group (INR target, 1.8) vs 3.8% (30 of 793) in the standard-treatment-warfarin group (INR target, 2.5), for a difference of 1.3% (1-sided 95% CI, -∞ to 3.05%, P = .06 for noninferiority). Major bleeding occurred in 0.4% of patients in the low-intensity group and 0.9% of patients in the standard-intensity group, for a difference of -0.5% (95% CI, -1.6% to 0.4%). The INR values of 4 or more occurred in 4.5% of patients in the low-intensity group and 12.2% of the standard-intensity group, for a difference of -7.8% (95% CI, -10.5% to -5.1%). CONCLUSIONS AND RELEVANCE Among older patients undergoing hip or knee arthroplasty and receiving warfarin prophylaxis, an international normalized ratio goal of 1.8 compared with 2.5 did not meet the criterion for noninferiority for risk of the composite outcome of VTE or death. However, the trial may have been underpowered to meet this criterion and further research may be warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01006733.
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Affiliation(s)
- Brian F. Gage
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Anne R. Bass
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Hannah Lin
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Massachusetts, Worcester
| | - Scott C. Woller
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Scott M. Stevens
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Noor Al-Hammadi
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Jeffrey L. Anderson
- Department of Medicine, University of Utah, Salt Lake City
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah
| | - Juan Li
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Tomás Rodriguez
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | | | - Amir K. Jaffer
- Department of Medicine, New York Presbyterian Queens Hospital, New York
| | - Cristi R. King
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Brandi Whipple
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Lynnae Napoli
- Department of Medicine, University of Utah, Salt Lake City
| | - Kerri Merritt
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Anna M. Thompson
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Central Florida College of Medicine, Orlando
| | - Gina Hyun
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Wesley Hollomon
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert L. Barrack
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ryan M. Nunley
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Gerard Moskowitz
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Victor Dávila-Román
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles S. Eby
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Pathology and Immunology, Washington University in St Louis, St Louis, Missouri
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Gage BF, Bass AR, Lin H, Woller SC, Stevens SM, Al-Hammadi N, Li J, Rodríguez T, Miller JP, McMillin GA, Pendleton RC, Jaffer AK, King CR, Whipple BD, Porche-Sorbet R, Napoli L, Merritt K, Thompson AM, Hyun G, Anderson JL, Hollomon W, Barrack RL, Nunley RM, Moskowitz G, Dávila-Román V, Eby CS. Effect of Genotype-Guided Warfarin Dosing on Clinical Events and Anticoagulation Control Among Patients Undergoing Hip or Knee Arthroplasty: The GIFT Randomized Clinical Trial. JAMA 2017; 318:1115-1124. [PMID: 28973620 PMCID: PMC5818817 DOI: 10.1001/jama.2017.11469] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Warfarin use accounts for more medication-related emergency department visits among older patients than any other drug. Whether genotype-guided warfarin dosing can prevent these adverse events is unknown. OBJECTIVE To determine whether genotype-guided dosing improves the safety of warfarin initiation. DESIGN, SETTING, AND PATIENTS The randomized clinical Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis included patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty and was conducted at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. INTERVENTIONS Patients were genotyped for the following polymorphisms: VKORC1-1639G>A, CYP2C9*2, CYP2C9*3, and CYP4F2 V433M. In a 2 × 2 factorial design, patients were randomized to genotype-guided (n = 831) or clinically guided (n = 819) warfarin dosing on days 1 through 11 of therapy and to a target international normalized ratio (INR) of either 1.8 or 2.5. The recommended doses of warfarin were open label, but the patients and clinicians were blinded to study group assignment. MAIN OUTCOMES AND MEASURES The primary end point was the composite of major bleeding, INR of 4 or greater, venous thromboembolism, or death. Patients underwent a screening lower-extremity duplex ultrasound approximately 1 month after arthroplasty. RESULTS Among 1650 randomized patients (mean age, 72.1 years [SD, 5.4 years]; 63.6% women; 91.0% white), 1597 (96.8%) received at least 1 dose of warfarin therapy and completed the trial (n = 808 in genotype-guided group vs n = 789 in clinically guided group). A total of 87 patients (10.8%) in the genotype-guided group vs 116 patients (14.7%) in the clinically guided warfarin dosing group met at least 1 of the end points (absolute difference, 3.9% [95% CI, 0.7%-7.2%], P = .02; relative rate [RR], 0.73 [95% CI, 0.56-0.95]). The numbers of individual events in the genotype-guided group vs the clinically guided group were 2 vs 8 for major bleeding (RR, 0.24; 95% CI, 0.05-1.15), 56 vs 77 for INR of 4 or greater (RR, 0.71; 95% CI, 0.51-0.99), 33 vs 38 for venous thromboembolism (RR, 0.85; 95% CI, 0.54-1.34), and there were no deaths. CONCLUSIONS AND RELEVANCE Among patients undergoing elective hip or knee arthroplasty and treated with perioperative warfarin, genotype-guided warfarin dosing, compared with clinically guided dosing, reduced the combined risk of major bleeding, INR of 4 or greater, venous thromboembolism, or death. Further research is needed to determine the cost-effectiveness of personalized warfarin dosing. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01006733.
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Affiliation(s)
- Brian F. Gage
- Washington University in St Louis, St Louis, Missouri
| | - Anne R. Bass
- Hospital for Special Surgery, New York, New York
| | - Hannah Lin
- Washington University in St Louis, St Louis, Missouri
- University of Massachusetts, Worcester
| | - Scott C. Woller
- Intermountain Healthcare, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Scott M. Stevens
- Intermountain Healthcare, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | | | - Juan Li
- Washington University in St Louis, St Louis, Missouri
| | | | | | | | | | - Amir K. Jaffer
- New York Presbyterian Queens Hospital, New York, New York
| | | | | | | | | | | | - Anna M. Thompson
- Washington University in St Louis, St Louis, Missouri
- University of Central Florida College of Medicine, Orlando
| | - Gina Hyun
- Washington University in St Louis, St Louis, Missouri
- Saint Louis University, St Louis, Missouri
| | - Jeffrey L. Anderson
- Intermountain Healthcare, Salt Lake City, Utah
- University of Utah, Salt Lake City
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Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson S, Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH, Anzai Y, Pendleton RC. Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. JAMA 2016; 316:1061-72. [PMID: 27623461 DOI: 10.1001/jama.2016.12226] [Citation(s) in RCA: 205] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.
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Shih L, Kaplan D, Kraiss LW, Casper TC, Pendleton RC, Peters CL, Supiano MA, Zimmerman GA, Weyrich AS, Rondina MT. Platelet-Monocyte Aggregates and C-Reactive Protein are Associated with VTE in Older Surgical Patients. Sci Rep 2016; 6:27478. [PMID: 27270163 PMCID: PMC4895334 DOI: 10.1038/srep27478] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/19/2016] [Indexed: 01/26/2023] Open
Abstract
Emerging evidence implicates platelets as key mediators of venous thromboembolism (VTE). Nevertheless, the pathways by which platelets and circulating procoagulant proteins synergistically orchestrate VTE remain incompletely understood. We prospectively determined whether activated platelets and systemic procoagulant factors were associated with VTE in 32 older orthopedic surgery patients. Circulating platelet-monocyte aggregates (PMAs), p-selectin expression (P-SEL), and integrin αIIbβ3 activation (PAC-1 binding) were assessed pre-operatively and 24 hours post-operatively. The proinflammatory and procoagulant molecule C-reactive protein (CRP), which induces PMA formation in vitro, along with plasma d-dimer and fibrinogen levels were also measured. The primary outcome was VTE occurring within 30 days post-operatively. Overall, 40.6% of patients developed VTE. Patients with VTE had a significant increase in circulating PMAs and CRP post-operatively, compared to those without VTE. Changes in PMA and CRP in VTE patients were significantly correlated (r2 = 0.536, p = 0.004). In contrast, P-SEL expression and PAC-1 binding, fibrinogen levels, and d-dimers were not associated with VTE. This is the first study to identify that increased circulating PMAs and CRP levels are early markers associated with post-surgical VTE. Our findings also provide new clinical evidence supporting the interplay between PMAs and CRP in patients with VTE.
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Affiliation(s)
- Lauren Shih
- Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | - David Kaplan
- Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake City, USA
| | - T Charles Casper
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, USA
| | - Robert C Pendleton
- Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | | | - Mark A Supiano
- Division of Geriatrics, University of Utah, Salt Lake City, USA
| | - Guy A Zimmerman
- Department of Internal Medicine, University of Utah, Salt Lake City, USA
| | - Andrew S Weyrich
- Department of Internal Medicine, University of Utah, Salt Lake City, USA.,Molecular Medicine Program at the University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Matthew T Rondina
- Department of Internal Medicine, University of Utah, Salt Lake City, USA.,Molecular Medicine Program at the University of Utah Health Sciences Center, Salt Lake City, Utah.,George E. Wahlen Salt Lake City VAMC GRECC, Salt Lake City, USA
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Kaplan D, Casper TC, Elliott CG, Men S, Pendleton RC, Kraiss LW, Weyrich AS, Grissom CK, Zimmerman GA, Rondina MT. VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock. Chest 2016; 148:1224-1230. [PMID: 26111103 DOI: 10.1378/chest.15-0287] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Prospective studies on the incidence of VTE during severe sepsis and septic shock remain absent, hindering efficacy assessments regarding VTE prevention strategies in sepsis. METHODS We prospectively studied 113 consecutively enrolled patients in the ICU with severe sepsis and septic shock at three hospitals. All patients provided informed consent. VTE thromboprophylaxis was recorded for all patients. Patients underwent ultrasonography and were followed for VTE prior to ICU discharge. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with VTE (including central venous catheter [CVC] insertion, age, length of stay, and mechanical ventilation) were included in a multivariable logistic regression analysis using backward stepwise elimination to determine VTE predictors. RESULTS Mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 18.2 ± 7.0, and age was 50 ± 18 years. Despite all patients receiving guideline-recommended thromboprophylaxis, the incidence of VTE was 37.2% (95% CI, 28.3-46.8). Most VTE events were clinically significant (defined as pulmonary embolism, proximal DVT, and/or symptomatic distal DVT) and associated with an increased length of stay (18.2 ± 9.9 days vs 13.4 ± 11.5 days, P < .05). Mortality was higher in patients with acute VTE but did not reach statistical significance. Insertion of a CVC and longer mechanical ventilation duration were significant VTE risk factors. VTE incidence did not differ by thromboprophylaxis type. CONCLUSIONS To our knowledge this is the first multicenter prospective study to identify a high incidence of VTE in patients with severe sepsis and septic shock, despite the use of universal, guideline-recommended thromboprophylaxis. Our findings suggest that the systemic inflammatory milieu of sepsis may uniquely predispose patients with sepsis to VTE. More effective VTE prevention strategies are necessary in patients with sepsis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02353910; URL: www.clinicaltrials.gov.
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Affiliation(s)
- David Kaplan
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - T Charles Casper
- Study Design and Biostatistics Center, University of Utah, Salt Lake City
| | - C Gregory Elliott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Shaohua Men
- Molecular Medicine Program, University of Utah, Salt Lake City
| | | | - Larry W Kraiss
- Eccles Institute of Human Genetics, and the Division of Vascular Surgery, University of Utah, Salt Lake City
| | - Andrew S Weyrich
- Department of Internal Medicine, University of Utah, Salt Lake City; Molecular Medicine Program, University of Utah, Salt Lake City
| | - Colin K Grissom
- Department of Internal Medicine, University of Utah, Salt Lake City; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Guy A Zimmerman
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Matthew T Rondina
- Department of Internal Medicine, University of Utah, Salt Lake City; Molecular Medicine Program, University of Utah, Salt Lake City.
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Kawamoto K, Martin CJ, Williams K, Tu MC, Park CG, Hunter C, Staes CJ, Bray BE, Deshmukh VG, Holbrook RA, Morris SJ, Fedderson MB, Sletta A, Turnbull J, Mulvihill SJ, Crabtree GL, Entwistle DE, McKenna QL, Strong MB, Pendleton RC, Lee VS. Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc 2014; 22:223-35. [PMID: 25324556 PMCID: PMC4433359 DOI: 10.1136/amiajnl-2013-002511] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective To develop expeditiously a pragmatic, modular, and extensible software framework for understanding and improving healthcare value (costs relative to outcomes). Materials and methods In 2012, a multidisciplinary team was assembled by the leadership of the University of Utah Health Sciences Center and charged with rapidly developing a pragmatic and actionable analytics framework for understanding and enhancing healthcare value. Based on an analysis of relevant prior work, a value analytics framework known as Value Driven Outcomes (VDO) was developed using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement. Results A modular, extensible framework was developed to allocate clinical care costs to individual patient encounters. For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. Conclusions The framework described can be expeditiously implemented to provide a pragmatic, modular, and extensible approach to understanding and improving healthcare value.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Amy Sletta
- University of Utah, Salt Lake City, Utah, USA
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Kimmel SE, French B, Kasner SE, Johnson JA, Anderson JL, Gage BF, Rosenberg YD, Eby CS, Madigan RA, McBane RB, Abdel-Rahman SZ, Stevens SM, Yale S, Mohler ER, Fang MC, Shah V, Horenstein RB, Limdi NA, Muldowney JAS, Gujral J, Delafontaine P, Desnick RJ, Ortel TL, Billett HH, Pendleton RC, Geller NL, Halperin JL, Goldhaber SZ, Caldwell MD, Califf RM, Ellenberg JH. A pharmacogenetic versus a clinical algorithm for warfarin dosing. N Engl J Med 2013; 369:2283-93. [PMID: 24251361 PMCID: PMC3942158 DOI: 10.1056/nejmoa1310669] [Citation(s) in RCA: 552] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The clinical utility of genotype-guided (pharmacogenetically based) dosing of warfarin has been tested only in small clinical trials or observational studies, with equivocal results. METHODS We randomly assigned 1015 patients to receive doses of warfarin during the first 5 days of therapy that were determined according to a dosing algorithm that included both clinical variables and genotype data or to one that included clinical variables only. All patients and clinicians were unaware of the dose of warfarin during the first 4 weeks of therapy. The primary outcome was the percentage of time that the international normalized ratio (INR) was in the therapeutic range from day 4 or 5 through day 28 of therapy. RESULTS At 4 weeks, the mean percentage of time in the therapeutic range was 45.2% in the genotype-guided group and 45.4% in the clinically guided group (adjusted mean difference, [genotype-guided group minus clinically guided group], -0.2; 95% confidence interval, -3.4 to 3.1; P=0.91). There also was no significant between-group difference among patients with a predicted dose difference between the two algorithms of 1 mg per day or more. There was, however, a significant interaction between dosing strategy and race (P=0.003). Among black patients, the mean percentage of time in the therapeutic range was less in the genotype-guided group than in the clinically guided group. The rates of the combined outcome of any INR of 4 or more, major bleeding, or thromboembolism did not differ significantly according to dosing strategy. CONCLUSIONS Genotype-guided dosing of warfarin did not improve anticoagulation control during the first 4 weeks of therapy. (Funded by the National Heart, Lung, and Blood Institute and others; COAG ClinicalTrials.gov number, NCT00839657.).
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Grantz MR, Proctor P, Skalabrin E, Pendleton RC, Majersik JJ. Abstract 238: Utilization and Safety of a Heparin Nomogram in Treating Thrombotic Comorbidities in Stroke Patients. Circ Cardiovasc Qual Outcomes 2013. [DOI: 10.1161/circoutcomes.6.suppl_1.a238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION:
AHA guidelines discourage anticoagulation in acute ischemic stroke (AIS) patients to prevent stroke recurrence. However, some AIS patients have concurrent thrombotic states, such as DVT/PE, that require anticoagulation to prevent further morbidity. Little is published on the safety and efficacy of heparin titration nomograms used for thrombotic comorbidities in stroke patients. Our aim was to assess the utilization and safety of a heparin stroke infusion nomogram at a single, tertiary, academic hospital.
METHODS:
The heparin stroke nomogram contains no heparin bolus, a goal aPTT of 60-85, and stable “steady state” dose with 2 consecutive aPTT values at goal. Patients were identified via a retrospective, computerized order entry review for the heparin nomogram. Exclusion criteria were: baseline aPTT > 50s, a hypercoagulable state, and short usage (< 24 hrs) or interrupted nomogram prior to 2 consecutive “goal” aPTT values. Demographic data and aPTTs were determined from the prospectively-populated enterprise data warehouse. The aPTTs were divided into 6 hr time bins from initiation. Indication and outcomes were determined by source document review by a stroke neurologist.
RESULTS:
From 1/2010 - 6/2011, a heparin nomogram for any indication was initiated in 2,016 patients with 144 (7%) of these utilizing the “stroke” heparin nomogram, The nomogram was ordered by neurology (72%, n=103 ), neurosurgery (8%, n=11), other surgical specialties (9%, n=13), internal medicine (7%, n=10), and other (5%, n=7). After excluding those as above, the “stroke” heparin nomogram was used in 86 patients (40% female; mean 55 yrs SD 17), 74 with AIS, 2 with ICH, 1 with SAH, 2 with craniectomy, and 3 other. The indication for heparin included large artery near total occlusion (30%, n=26), cardiac thrombus (suspected (26%, n=22) or visualized (9%, n=8)), cerebral sinus venous thrombosis (10%, n=9), DVT/PE (5%, n=4), artery dissection (17%, n=15), and other (7%, n=6).
Percent of “at-goal” aPTTs by 6 hr time bins were: 6-12 hrs: 24% (n=21/86); 12-18 hrs: 36% (n=31/ 86); 18-24 hrs: 48% (n=40/84); 24-48 hrs: 55% (n=42/77); 48+ hrs: 65% (n=29/45). At the 42-48 hrs time point, 4% of patients had aPTT>150.
There were 4 non-bleeding related deaths. Repeat AIS occurred in 3 patients of the 74 patients with primary AIS. Asymptomatic ICH occurred in 1 patient with primary AIS; symptomatic hemorrhage occurred in 2 patients (epistaxis, GI). Discharge anticoagulation was prescribed in 56 patients (65%). Ninety day readmission occurred in 15% of patients (n=13), 5 for bleeding.
CONCLUSION:
The heparin stroke nomogram appears safe in that it does not increase risk of ICH. However, therapeutic aPTTs are not reached quickly with less than half of patients therapeutic at 24 hours, nor are they maintained at steady state. This nomogram could be too conservative in cases where clinical situation requires rapid anticoagulation.
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11
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Sehdev A, Wanner N, Pendleton RC. Statins for the prevention of venous thromboembolism? a narrative review. Hosp Pract (1995) 2012; 40:13-8. [PMID: 23086090 DOI: 10.3810/hp.2012.08.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a substantial public health problem. The majority of VTE events are associated with transient periods of heightened risk, such as prolonged hospitalization, undergoing major surgery, experiencing trauma or lower extremity immobility, use of oral contraceptives, or having active cancer. Although pharmacologic thromboprophylaxis agents (eg, unfractionated heparin, low-molecular-weight heparins, warfarin, and novel oral anticoagulants) are effective, they remain underused, with concerns about increased bleeding risk often cited as a reason. The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (ie, statins), although used primarily for lipid lowering and arterial thrombosis risk reduction, have pleiotrophic effects that affect coagulation and inflammation, and do not increase bleeding risk. There is emerging evidence to suggest that through these pleiotrophic effects, statins may be effective in reducing the incidence of VTE. This article summarizes the literature with regard to statins' effect on VTE and suggests that additional investigations are needed to assess a potential adjunctive role for primary VTE thromboprophylaxis.
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Affiliation(s)
- Amikar Sehdev
- Visiting Instructor, Department of General Internal Medicine, University of Utah Hospital, Salt Lake City, UT.
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12
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Adams TD, Davidson LE, Litwin SE, Kolotkin RL, LaMonte MJ, Pendleton RC, Strong MB, Vinik R, Wanner NA, Hopkins PN, Gress RE, Walker JM, Cloward TV, Nuttall RT, Hammoud A, Greenwood JLJ, Crosby RD, McKinlay R, Simper SC, Smith SC, Hunt SC. Health benefits of gastric bypass surgery after 6 years. JAMA 2012; 308:1122-31. [PMID: 22990271 PMCID: PMC3744888 DOI: 10.1001/2012.jama.11164] [Citation(s) in RCA: 452] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Extreme obesity is associated with health and cardiovascular disease risks. Although gastric bypass surgery induces rapid weight loss and ameliorates many of these risks in the short term, long-term outcomes are uncertain. OBJECTIVE To examine the association of Roux-en-Y gastric bypass (RYGB) surgery with weight loss, diabetes mellitus, and other health risks 6 years after surgery. DESIGN, SETTING, AND PARTICIPANTS A prospective Utah-based study conducted between July 2000 and June 2011 of 1156 severely obese (body mass index [BMI] ≥ 35) participants aged 18 to 72 years (82% women; mean BMI, 45.9; 95% CI, 31.2-60.6) who sought and received RYGB surgery (n = 418), sought but did not have surgery (n = 417; control group 1), or who were randomly selected from a population-based sample not seeking weight loss surgery (n = 321; control group 2). MAIN OUTCOME MEASURES Weight loss, diabetes, hypertension, dyslipidemia, and health-related quality of life were compared between participants having RYGB surgery and control participants using propensity score adjustment. RESULTS Six years after surgery, patients who received RYGB surgery (with 92.6% follow-up) lost 27.7% (95% CI, 26.6%-28.9%) of their initial body weight compared with 0.2% (95% CI, -1.1% to 1.4%) gain in control group 1 and 0% (95% CI, -1.2% to 1.2%) in control group 2. Weight loss maintenance was superior in patients who received RYGB surgery, with 94% (95% CI, 92%-96%) and 76% (95% CI, 72%-81%) of patients receiving RYGB surgery maintaining at least 20% weight loss 2 and 6 years after surgery, respectively. Diabetes remission rates 6 years after surgery were 62% (95% CI, 49%-75%) in the RYGB surgery group, 8% (95% CI, 0%-16%) in control group 1, and 6% (95% CI, 0%-13%) in control group 2, with remission odds ratios (ORs) of 16.5 (95% CI, 4.7-57.6; P < .001) vs control group 1 and 21.5 (95% CI, 5.4-85.6; P < .001) vs control group 2. The incidence of diabetes throughout the course of the study was reduced after RYGB surgery (2%; 95% CI, 0%-4%; vs 17%; 95% CI, 10%-24%; OR, 0.11; 95% CI, 0.04-0.34 compared with control group 1 and 15%; 95% CI, 9%-21%; OR, 0.21; 95% CI, 0.06-0.67 compared with control group 2; both P < .001). The numbers of participants with bariatric surgery-related hospitalizations were 33 (7.9%), 13 (3.9%), and 6 (2.0%) for the RYGB surgery group and 2 control groups, respectively. CONCLUSION Among severely obese patients, compared with nonsurgical control patients, the use of RYGB surgery was associated with higher rates of diabetes remission and lower risk of cardiovascular and other health outcomes over 6 years.
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Affiliation(s)
- Ted D Adams
- Department of Internal Medicine, University of Utah School of Medicine, 420 Chipeta Way, Room 1160, Salt Lake City, UT 84108, USA.
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13
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Borgman MP, Pendleton RC, McMillin GA, Reynolds KK, Vazquez S, Freeman A, Wilson A, Valdes R, Linder MW. Prospective pilot trial of PerMIT versus standard anticoagulation service management of patients initiating oral anticoagulation. Thromb Haemost 2012; 108:561-9. [PMID: 22836303 DOI: 10.1160/th12-03-0159] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/25/2012] [Indexed: 11/05/2022]
Abstract
We performed a randomised pilot trial of PerMIT, a novel decision support tool for genotype-based warfarin initiation and maintenance dosing, to assess its efficacy for improving warfarin management. We prospectively studied 26 subjects to compare PerMIT-guided management with routine anticoagulation service management. CYP2C9 and VKORC1 genotype results for 13 subjects randomly assigned to the PerMIT arm were recorded within 24 hours of enrolment. To aid in INR interpretation, PerMIT calculates estimated loading and maintenance doses based on a patient's genetic and clinical characteristics and displays calculated S-warfarin plasma concentrations based on planned or administered dosages. In comparison to control subjects, patients in the PerMIT study arm demonstrated a 3.6-day decrease in the time to reach a stabilised INR within the target therapeutic range (4.7 vs. 8.3 days, p = 0.015); a 12.8% increase in time spent within the therapeutic interval over the first 25 days of therapy (64.3% vs. 55.3%, p = 0.180); and a 32.9% decrease in the frequency of warfarin dose adjustments per INR measurement (38.3% vs. 57.1%, p = 0.007). Serial measurements of plasma S-warfarin concentrations were also obtained to prospectively evaluate the accuracy of the pharmacokinetic model during induction therapy. The PerMIT S-warfarin plasma concentration model estimated 62.8% of concentrations within 0.15 mg/l. These pilot data suggest that the PerMIT method and its incorporation of genotype/phenotype information may help practitioners increase the safety, efficacy, and efficiency of warfarin therapeutic management.
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14
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Freeman A, Horner T, Pendleton RC, Rondina MT. Prospective comparison of three enoxaparin dosing regimens to achieve target anti-factor Xa levels in hospitalized, medically ill patients with extreme obesity. Am J Hematol 2012; 87:740-3. [PMID: 22565589 DOI: 10.1002/ajh.23228] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Enoxaparin is commonly used to prevent venous thromboembolism(VTE) [1,2] but has not been well-studied in patients with extreme obesity,a population at high risk for VTE. We prospectively compared three enoxaparin dosing regimens for the achievement of goal peak anti-Factor Xa levels in medically ill patients (n 5 31) with extreme obesity (body mass index (BMI) ‡ 40 kg/m2). Patients were assigned to receive fixed-dose (FD) enoxaparin 40 mg daily (QDay, n 5 11), weight based,lower-dose (LD) enoxaparin 0.4 mg/kg QDay (n 5 9), or weight based,higher-dose (HD) enoxaparin 0.5 mg/kg QDay (n 5 11). The average BMI and weight of the entire cohort was 62.1 kg/m2 (range40.5–82.4) and 176 kg (range 115–256 kg) and did not differ between groups. Peak anti-Factor Xa levels were significantly higher in the HD group compared to either LD or FD groups. Patients in the HD group achieved target anti-Factor Xa levels more frequently than the LD and FD groups (P < 0.05). Peak anti-Factor Xa levels did not correlate with age, weight, BMI, or creatinine clearance, demonstrating the predictability of weight-based enoxaparin dosing. There were no adverse events (e.g., bleeding, thrombosis, thrombocytopenia). To our knowledge this is the first prospective comparative study demonstrating that in extremely obese, medically ill patients enoxaparin 0.5 mg/kg QDay is superior to FD and LD enoxaparin for the achievement of target anti-Factor Xa levels.
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Affiliation(s)
- Andrew Freeman
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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15
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Freeman AL, Pendleton RC. ACP Journal Club. Review: VTE prophylaxis in nonsurgical inpatients reduces PE but not death, and increases major bleeding. Ann Intern Med 2012; 156:JC2-05. [PMID: 22351731 DOI: 10.7326/0003-4819-156-4-201202210-02005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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16
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Horne BD, Lenzini PA, Wadelius M, Jorgensen AL, Kimmel SE, Ridker PM, Eriksson N, Anderson JL, Pirmohamed M, Limdi NA, Pendleton RC, McMillin GA, Burmester JK, Kurnik D, Stein CM, Caldwell MD, Eby CS, Rane A, Lindh JD, Shin JG, Kim HS, Angchaisuksiri P, Glynn RJ, Kronquist KE, Carlquist JF, Grice GR, Barrack RL, Li J, Gage BF. Pharmacogenetic warfarin dose refinements remain significantly influenced by genetic factors after one week of therapy. Thromb Haemost 2012; 107:232-40. [PMID: 22186998 PMCID: PMC3292349 DOI: 10.1160/th11-06-0388] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 11/04/2011] [Indexed: 01/06/2023]
Abstract
By guiding initial warfarin dose, pharmacogenetic (PGx) algorithms may improve the safety of warfarin initiation. However, once international normalised ratio (INR) response is known, the contribution of PGx to dose refinements is uncertain. This study sought to develop and validate clinical and PGx dosing algorithms for warfarin dose refinement on days 6-11 after therapy initiation. An international sample of 2,022 patients at 13 medical centres on three continents provided clinical, INR, and genetic data at treatment days 6-11 to predict therapeutic warfarin dose. Independent derivation and retrospective validation samples were composed by randomly dividing the population (80%/20%). Prior warfarin doses were weighted by their expected effect on S-warfarin concentrations using an exponential-decay pharmacokinetic model. The INR divided by that "effective" dose constituted a treatment response index . Treatment response index, age, amiodarone, body surface area, warfarin indication, and target INR were associated with dose in the derivation sample. A clinical algorithm based on these factors was remarkably accurate: in the retrospective validation cohort its R(2) was 61.2% and median absolute error (MAE) was 5.0 mg/week. Accuracy and safety was confirmed in a prospective cohort (N=43). CYP2C9 variants and VKORC1-1639 G→A were significant dose predictors in both the derivation and validation samples. In the retrospective validation cohort, the PGx algorithm had: R(2)= 69.1% (p<0.05 vs. clinical algorithm), MAE= 4.7 mg/week. In conclusion, a pharmacogenetic warfarin dose-refinement algorithm based on clinical, INR, and genetic factors can explain at least 69.1% of therapeutic warfarin dose variability after about one week of therapy.
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Affiliation(s)
- Benjamin D Horne
- Cardiovascular Department, Intermountain Medical Center, Salt Lake City, Utah 84107, USA.
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17
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Wilcox R, Pendleton RC, Smock KJ, Rodgers GM. Hospital-based clinical implications of the novel oral anticoagulant, dabigatran etexilate, in daily practice. Hosp Pract (1995) 2011; 39:23-34. [PMID: 21881389 DOI: 10.3810/hp.2011.08.576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dabigatran etexilate is an oral direct thrombin inhibitor that has been approved by the US Food and Drug Administration for the prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation. It has also been studied for the prevention of venous thromboembolism in patients after hip and knee arthroplasty and for treatment of venous thromboembolism. Although routine laboratory monitoring is not needed, there are clinical scenarios in which physicians will need to have a clear understanding of drug pharmacology, laboratory assessment, and reversibility of this drug to make appropriate clinical decisions. We review the pharmacology of dabigatran etexilate, pertinent clinical trials, and the effects of dabigatran etexilate on prothrombin time, activated partial thromboplastin time, thrombin time, and ecarin clotting time. We also provide an approach to patients on dabigatran etexilate who are bleeding, have a suspected therapeutic failure, or require periprocedural management.
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Affiliation(s)
- Ryan Wilcox
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, UT, USA.
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18
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Abstract
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in hospitalized patients. Where appropriate, evidence-based methods of prophylaxis are implemented and the burden of VTE can be reduced substantially. Obesity, including morbid obesity, is associated with a high risk of VTE and, unfortunately, fixed doses of US FDA-approved anticoagulant regimens, including unfractionated heparins, low-molecular-weight heparins and factor Xa inhibitors, may not provide optimal VTE prophylaxis in these patients. Although the data are still limited, a rapidly growing body of literature and cumulative evidence suggests that anticoagulant dose adjustments in morbidly obese patients may optimize pharmacodynamic activity and reduce VTE risk. With the prevalence of morbid obesity continuing to rise, more high-quality clinical data are needed to better understand the pathobiology of VTE in obesity and provide effective, yet safe, prevention strategies.
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Affiliation(s)
- Andrew L Freeman
- University of Utah Department of Internal Medicine, 50 North Medical Drive, Room 4B120, School of Medicine, Salt Lake City, UT 84132, USA
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19
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Abstract
Hip fracture is an unfortunate and common health problem in the elderly that is associated with a 1-year mortality of 10% to 35%. Further, only 50% of these patients regain their pre-fracture level of mobility and functional status. Hospital-based clinicians are increasingly asked to comanage these patients. The purpose of this article is to summarize evidence-based clinical management practices that are relevant to hospitalist clinicians who manage hip fracture patients, and to highlight the current evidence for implementing a formal hospitalist and orthopedic comanagement care model.
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Affiliation(s)
- Jason Hughson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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20
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Pendleton RC, Rodgers GM, Hull RD. Established Venous Thromboembolism Therapies: Heparin, Low Molecular Weight Heparins, and Vitamin K Antagonists, with a Discussion of Heparin-Induced Thrombocytopenia. Clin Chest Med 2010; 31:691-706. [DOI: 10.1016/j.ccm.2010.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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21
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Vinik R, Pendleton RC, Jones RE. In response to: Safety and efficacy of continuous insulin infusion in noncritical care settings. J Hosp Med 2010; 5:E10. [PMID: 20803663 DOI: 10.1002/jhm.801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Graves KK, Green LS, Pendleton RC. Pulmonary embolism with unexpected echocardiogram findings. Hosp Pract (1995) 2010; 38:84-8. [PMID: 20469628 DOI: 10.3810/hp.2010.02.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 56-year-old woman was evaluated for dyspnea in the emergency department. She had no risk factors for venous thromboembolism except hormone replacement therapy; however, pulmonary embolism was suspected and subsequently confirmed via computed tomographic angiogram. An echocardiogram was conducted to further assess right ventricular function, revealing marked right ventricular enlargement and a mobile mass in the left atrium (initially suspected to be an atrial myxoma). After subsequent embolization to the left axillary artery, thrombolysis was administered, and embolectomy confirmed this to be thrombus. A repeat echocardiogram showed resolution. This case highlights that although echocardiography can be helpful in risk stratification when assessing patients with pulmonary embolism, unexpected findings may be encountered. When clinicians identify multiple clinical findings, Occam's razor suggests that these multiple findings are most likely related.
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Affiliation(s)
- Kencee K Graves
- University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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23
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Lenzini P, Wadelius M, Kimmel S, Anderson JL, Jorgensen AL, Pirmohamed M, Caldwell MD, Limdi N, Burmester JK, Dowd MB, Angchaisuksiri P, Bass AR, Chen J, Eriksson N, Rane A, Lindh JD, Carlquist JF, Horne BD, Grice G, Milligan PE, Eby C, Shin J, Kim H, Kurnik D, Stein CM, McMillin G, Pendleton RC, Berg RL, Deloukas P, Gage BF. Integration of genetic, clinical, and INR data to refine warfarin dosing. Clin Pharmacol Ther 2010; 87:572-8. [PMID: 20375999 PMCID: PMC2858245 DOI: 10.1038/clpt.2010.13] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Well-characterized genes that affect warfarin metabolism (cytochrome P450 (CYP) 2C9) and sensitivity (vitamin K epoxide reductase complex 1 (VKORC1)) explain one-third of the variability in therapeutic dose before the international normalized ratio (INR) is measured. To determine genotypic relevance after INR becomes available, we derived clinical and pharmacogenetic refinement algorithms on the basis of INR values (on day 4 or 5 of therapy), clinical factors, and genotype. After adjusting for INR, CYP2C9 and VKORC1 genotypes remained significant predictors (P < 0.001) of warfarin dose. The clinical algorithm had an R(2) of 48% (median absolute error (MAE): 7.0 mg/week) and the pharmacogenetic algorithm had an R(2) of 63% (MAE: 5.5 mg/week) in the derivation set (N = 969). In independent validation sets, the R(2) was 26-43% with the clinical algorithm and 42-58% when genotype was added (P = 0.002). After several days of therapy, a pharmacogenetic algorithm estimates the therapeutic warfarin dose more accurately than one using clinical factors and INR response alone.
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Affiliation(s)
- P Lenzini
- Department of Internal Medicine, Washington University, St Louis, Missouri, USA
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24
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Rondina MT, Walker A, Pendleton RC. Drug-induced thrombocytopenia for the hospitalist physician with a focus on heparin-induced thrombocytopenia. Hosp Pract (1995) 2010; 38:19-28. [PMID: 20469610 PMCID: PMC3682781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Acute thrombocytopenia occurs commonly in hospitalized patients. For most, the etiology of an acutely declining platelet count is obvious and includes sepsis with disseminated intravascular coagulation, large-volume crystalloid infusion, or the administration of cytotoxic therapies, such as chemotherapeutic agents. For others, however, the etiology may be less apparent. In these cases, drug-induced thrombocytopenia (DIT), including heparin-induced thrombocytopenia (HIT), must be a diagnostic consideration. The approach to the hospitalized patient with thrombocytopenia, without an obvious cause, includes a careful medication history to identify potential culprits, such as glycoprotein IIb/IIIa inhibitors, vancomycin, linezolid, beta-lactam antibiotics, quinine, antiepileptic drugs, or heparin/low-molecular-weight heparin. Usually, discontinuation of the offending medication is all that is necessary for resolution of thrombocytopenia. Heparin-induced thrombocytopenia, however, is an exception to this general rule given its unique pathogenesis and propensity for thrombotic complications and death. Differentiating between HIT and DIT due to nonheparin medications may prove challenging. Through a careful clinical assessment, consideration of the pre-test probability for HIT, and the thoughtful application of laboratory testing, HIT can be accurately diagnosed. Because patients with HIT have a high risk of thrombosis and bleeding is uncommon, the prompt initiation of an alternative anticoagulant (e.g., a direct thrombin inhibitor) is warranted in these patients.
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Affiliation(s)
- Matthew T Rondina
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84112, USA.
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25
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Pendleton RC, Wheeler M, Wanner N, Strong MB, Vinik R, Peters CL. A safe, effective, and easy to use warfarin initiation dosing nomogram for post-joint arthroplasty patients. J Arthroplasty 2010; 25:121-7. [PMID: 19062248 DOI: 10.1016/j.arth.2008.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 09/21/2008] [Indexed: 02/01/2023] Open
Abstract
Venous thromboembolism (VTE) is a complication after joint arthroplasty, and pharmacologic prophylaxis is recommended to reduce this risk. Warfarin is often used, but initial dosing and management can be difficult. We studied a single-center prospective cohort of consecutive (n = 351) post-joint arthroplasty/revision patients who were initiated on warfarin using a new initiation nomogram and then discharged to home with home health services. The mean time to an international normalized ratio (INR) of 2.0 or higher was 5 days, with a mean INR of 2.1 on the fifth postoperative day. Two patients (0.6%) had an INR higher than 5 in the first 10 days of therapy. Adverse events were uncommon: 4 patients (1.14%) had VTE, 1 had major bleeding episode, and 6 patients (1.7%) had minor bleeding. A specific warfarin dosing nomogram managed by an anticoagulation service and used in joint arthroplasty/revision patients who are discharged to home with home health services leads to effective anticoagulation with few associated adverse events.
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Affiliation(s)
- Robert C Pendleton
- Department of Medicine, General Internal Medicine, University Healthcare Thrombosis Service, University of Utah, Salt Lake City, Utah 84132, USA
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26
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Adams TD, Pendleton RC, Strong MB, Kolotkin RL, Walker JM, Litwin SE, Berjaoui WK, LaMonte MJ, Cloward TV, Avelar E, Owan TE, Nuttall RT, Gress RE, Crosby RD, Hopkins PN, Brinton EA, Rosamond WD, Wiebke GA, Yanowitz FG, Farney RJ, Halverson RC, Simper SC, Smith SC, Hunt SC. Health outcomes of gastric bypass patients compared to nonsurgical, nonintervened severely obese. Obesity (Silver Spring) 2010; 18:121-30. [PMID: 19498344 PMCID: PMC2864142 DOI: 10.1038/oby.2009.178] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Favorable health outcomes at 2 years postbariatric surgery have been reported. With exception of the Swedish Obesity Subjects (SOS) study, these studies have been surgical case series, comparison of surgery types, or surgery patients compared to subjects enrolled in planned nonsurgical intervention. This study measured gastric bypass effectiveness when compared to two separate severely obese groups not participating in designed weight-loss intervention. Three groups of severely obese subjects (N = 1,156, BMI >or= 35 kg/m(2)) were studied: gastric bypass subjects (n = 420), subjects seeking gastric bypass but did not have surgery (n = 415), and population-based subjects not seeking surgery (n = 321). Participants were studied at baseline and 2 years. Quantitative outcome measures as well as prevalence, incidence, and resolution rates of categorical health outcome variables were determined. All quantitative variables (BMI, blood pressure, lipids, diabetes-related variables, resting metabolic rate (RMR), sleep apnea, and health-related quality of life) improved significantly in the gastric bypass group compared with each comparative group (all P < 0.0001, except for diastolic blood pressure and the short form (SF-36) health survey mental component score at P < 0.01). Diabetes, dyslipidemia, and hypertension resolved much more frequently in the gastric bypass group than in the comparative groups (all P < 0.001). In the surgical group, beneficial changes of almost all quantitative variables correlated significantly with the decrease in BMI. We conclude that Roux-en-Y gastric bypass surgery when compared to severely obese groups not enrolled in planned weight-loss intervention was highly effective for weight loss, improved health-related quality of life, and resolution of major obesity-associated complications measured at 2 years.
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Affiliation(s)
- Ted D Adams
- Department of Internal Medicine, Cardiovascular Genetics Division, University of Utah, Salt Lake City, Utah, USA.
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Abstract
Many patients who are on long-term antithrombotic therapy (e.g. warfarin and/or antiplatelet agents) must be assessed for temporary discontinuation for a procedure or surgery, making this a salient topic for the hospitalist physician. Discontinuation of antithromhotic therapy can place patients at increased risk of thromboembolic complications while continuing antithrombotic therapy can increase procedure-related bleeding risk. Bridging anticoagulation with heparin or low molecular weight heparins is often used in the periprocedural period, but a great deal of uncertainty exists about how and when to use bridging anticoagulation. Because there is very little Level 1 evidence to define optimal care, both clinical practice and expert consensus guideline opinions vary. For the hospitalist, it is of critical importance to understand the available data, controversies, and management options in order to approach patient care rationally. This review provides a step-wise literature-based discussion addressing the following four questions: (1) What is the optimal management of antiplatelet therapy in the periprocedural period? (2) Are there very low bleeding risk procedures that do not require interruption of oral anticoagulation? (3) Are there low thromboembolic risk populations who do not require periprocedural bridging? (4) How do you manage patients who must discontinue anti-coagulants but are at an increased thrombotic risk?
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Affiliation(s)
- Russell Vinik
- Department of Internal Medicine, General Medicine Hospitalist Group, University of Utah, Salt Lake City, Utah 84132, USA.
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Pendleton RC, Vazquez S. Vitamin K to correct overanticoagulation. Ann Intern Med 2009; 151:433-4; author reply 435. [PMID: 19755376 DOI: 10.7326/0003-4819-151-6-200909150-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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29
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Piazza G, Rosenbaum EJ, Pendergast W, Jacobson JO, Pendleton RC, McLaren GD, Elliott CG, Stevens SM, Patton WF, Dabbagh O, Paterno MD, Catapane E, Li Z, Goldhaber SZ. Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients. Circulation 2009; 119:2196-201. [PMID: 19364975 DOI: 10.1161/circulationaha.108.841197] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis. METHODS AND RESULTS We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis. We randomized 2493 patients (82% on Medical Services) from 25 study sites to the intervention group (n=1238), in which the responsible physician was alerted by another hospital staff member, or the control group (n=1255), in which no alert was issued. The primary end point was symptomatic, objectively confirmed VTE within 90 days. Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis as control subjects (46.0% versus 20.6%; P<0.0001). The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% CI, 0.50 to 1.25), but the difference did not achieve statistical significance. The rate of major bleeding at 30 days in the alert group was similar to that in the control group (2.1% versus 2.3%; P=0.68). CONCLUSIONS A strategy of direct notification of the physician by a staff member increases prophylaxis use and leads to a reduction in the rate of symptomatic VTE in hospitalized patients. However, VTE prophylaxis continues to be underused even after physician notification, especially among Medical Service patients.
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Affiliation(s)
- Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Rondina MT, Wheeler M, Rodgers GM, Draper L, Pendleton RC. Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients. Thromb Res 2009; 125:220-3. [PMID: 19272635 DOI: 10.1016/j.thromres.2009.02.003] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Revised: 01/27/2009] [Accepted: 02/05/2009] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In clinical trials, fixed-dose enoxaparin (40 mg once daily) reduces the risk of venous thromboembolism (VTE) in medically-ill patients. However, morbidly obese patients were under-represented in these trials and using fixed-dose enoxaparin in obese patients may be inadequate. We completed a pharmacokinetic study in morbidly obese, medically-ill patients to determine if weight-based dosing of enoxaparin for VTE prophylaxis was feasible, without excessive levels of anticoagulation, as determined by peak anti-Xa levels. MATERIALS AND METHODS Twenty eight morbidly obese (BMI>or=35 kg/m(2)) patients were enrolled and completed the study protocol. Enoxaparin 0.5 mg/kg was administered once daily subcutaneously and peak anti-Xa levels were measured approximately 4-6 hours after the enoxaparin dose. RESULTS AND CONCLUSIONS Overall, 46% of patients were female, the average age (+/-SD) was 54 (+/-11) years, and the average weight and BMI were 135.6 kg (+/-25.3) and 48.1 kg/m(2) (+/-11.1), respectively. The average daily dose of enoxaparin was 67 mg (+/-12). The average peak anti-Xa level was 0.25 (SD+/-0.11, range 0.08 to 0.59) units/mL. Peak anti-Xa levels did not significantly correlate with weight or BMI. There were no bleeding events, symptomatic VTE, or significant thrombocytopenia. In morbidly obese, medically-ill patients, use of weight-based enoxaparin dosed at 0.5 mg/kg once daily is feasible and results in peak anti-Xa levels within or near recommended range for thromboprophylaxis, without any evidence of excessive anti-Xa activity. These data suggest that this weight-based regimen may be more effective than standard fixed-dose enoxaparin. Clinical outcome studies are warranted to determine the clinical safety and efficacy of this regimen.
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Affiliation(s)
- Matthew T Rondina
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah 84132, USA.
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31
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Abstract
OBJECTIVE To describe a case of azathioprine-induced warfarin resistance, present a literature review on warfarin-azathioprine interactions, and provide recommendations on appropriate management of this clinically significant interaction. CASE SUMMARY A 29-year-old female with Cogan's syndrome experienced thrombosis of the left internal carotid artery. She was treated with an average weekly warfarin dose of 39 mg (5.5 mg daily) prior to beginning azathioprine therapy. Three weeks following initiation of azathioprine 150 mg daily, the international normalized ratio (INR) decreased from 1.9 (prior to the medication change) to 1.0 without any change in the warfarin dose or other relevant factors. Over several weeks, the patient's warfarin dose was titrated up to 112 mg weekly (16 mg daily) to achieve an INR of 2.5 (a 188%, or 2.9-fold dose increase). Because of elevated liver enzyme levels, the azathioprine dosage was decreased to 100 mg daily. Within 2 weeks following that decrease, warfarin requirements decreased to 105 mg weekly (15 mg daily). DISCUSSION Azathioprine was the probable causative agent of warfarin resistance according to the Naranjo probability scale, and a possible causative agent according to the Drug Interaction Probability Scale. A literature search (PubMed, 1966-December 2007) revealed 8 case reports of this drug interaction and 2 cases involving a similar effect with 6-mercaptopurine, the active metabolite of azathioprine. The exact mechanism of the interaction remains unknown. Previously published case reports point to a rapid onset and offset of the warfarin-azathioprine interaction and a dose-dependent increase of at least 2.5-fold in warfarin dose requirement with the initiation of azathioprine 75-200 mg daily. CONCLUSIONS This case report and several others point toward azathioprine as a clinically significant inducer of warfarin resistance. Providers should anticipate the need for higher warfarin doses, warfarin dose adjustment, and close INR monitoring in patients receiving azathioprine or its active metabolite, 6-mercaptopurine.
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Affiliation(s)
- Sara R Vazquez
- UDepartment of Pharmacy Services, University Thrombosis Service, University of Utah, Salt Lake City, UT 84108, USA.
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Avelar E, Cloward TV, Walker JM, Farney RJ, Strong M, Pendleton RC, Segerson N, Adams TD, Gress RE, Hunt SC, Litwin SE. Left ventricular hypertrophy in severe obesity: interactions among blood pressure, nocturnal hypoxemia, and body mass. Hypertension 2006; 49:34-9. [PMID: 17130310 DOI: 10.1161/01.hyp.0000251711.92482.14] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Obese subjects have a high prevalence of left ventricular (LV) hypertrophy. It is unclear to what extent LV hypertrophy results directly from obesity or from associated conditions, such as hypertension, impaired glucose homeostasis, or obstructive sleep apnea. We tested the hypothesis that LV hypertrophy in severe obesity is associated with additive effects from each of the major comorbidities. Echocardiography and laboratory testing were performed in 455 severely obese subjects with body mass index 35 to 92 kg/m(2) and 59 nonobese reference subjects. LV hypertrophy, defined by allometrically corrected (LV mass/height(2.7)), gender-specific criteria, was present in 78% of the obese subjects. Multivariable regression analyses showed that average nocturnal oxygen saturation <85% was the strongest independent predictor of LV hypertrophy (P<0.001), followed by systolic blood pressure (P<0.015) and then body mass index (P<0.05). With regard to LV mass, there were synergistic effects between hypertension and body mass index (P interaction <0.001) and between hypertension and reduced nocturnal oxygen saturation. Severely obese subjects had normal LV endocardial fractional shortening (35+/-6% versus 35+/-6%) but mildly decreased midwall fractional shortening (15+/-2% versus 17+/-2%; P<0.001), indicating subtle myocardial dysfunction. In conclusion, more severe nocturnal hypoxemia, increasing systolic blood pressure, and body mass index are all independently associated with increased LV mass. The effects of increased blood pressure seem to amplify those of sleep apnea and more severe obesity.
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Affiliation(s)
- Erick Avelar
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA
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Creekmore FM, Oderda GM, Pendleton RC, Brixner DI. Incidence and Economic Implications of Heparin-Induced Thrombocytopenia in Medical Patients Receiving Prophylaxis for Venous Thromboembolism. Pharmacotherapy 2006; 26:1438-45. [PMID: 16999654 DOI: 10.1592/phco.26.10.1438] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVES To determine the incidence of heparin-induced thrombocytopenia (HIT) in patients admitted to a medical service who were given unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to prevent venous thromboembolism, the incremental cost of developing HIT, and the cost consequences of using LMWH to prevent venous thromboembolism in medical patients. DESIGN Retrospective analysis with a nested case-control. SETTING University-affiliated tertiary-care hospital. PATIENTS A total of 10,121 adult medical patients admitted between August 1, 2000, and November 2, 2004, received UFH or LMWH to prevent venous thromboembolism during their admission. From these, patients with immune-mediated HIT were identified and served as case patients, and 3-5 matched control patients were identified for each case patient. MEASUREMENTS AND MAIN RESULTS The development of HIT was determined for patients who received LMWH and for patients who received UFH. Costs were compared between the patients with HIT and the matched control patients. The cost of using LMWH to prevent venous thromboembolism was compared with the cost of using UFH. In patients receiving UFH and those receiving LMWH, the incidence of HIT was 0.51% (43/8420) and 0.084% (1/1189), respectively (p=0.037), with an overall incidence of 0.43% (44/10,121). Admissions that included development of HIT incurred an average cost of 56,364 dollars compared with 15,231 dollars (p<0.001) for admissions without HIT. Using LMWH to prevent venous thromboembolism in medical patients cost 13.88 dollars less per patient than using UFH. CONCLUSIONS For the prophylaxis of venous thromboembolism, LMWH was associated with a lower incidence of HIT than UFH in medical patients. An admission during which the patient develops HIT costs significantly more than an admission during which the patient does not develop HIT. Low-molecular-weight heparin is cost-effective for prevention of venous thromboembolism in medical patients.
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Pendleton RC, Rodgers GM, Wiener CM. A necessary detour. Am J Med 2006; 119:651-3. [PMID: 16887407 DOI: 10.1016/j.amjmed.2006.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Revised: 06/09/2006] [Accepted: 06/09/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Robert C Pendleton
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
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35
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Rondina MT, Pendleton RC, Wheeler M, Rodgers GM. The treatment of venous thromboembolism in special populations. Thromb Res 2006; 119:391-402. [PMID: 16879860 DOI: 10.1016/j.thromres.2006.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 04/14/2006] [Accepted: 05/30/2006] [Indexed: 10/24/2022]
Abstract
Anticoagulant therapy for the typical venous thromboembolism patient is straightforward with predictably favorable outcomes. However, for certain patients with venous thromboembolism, there remains uncertainty and controversy about optimal treatment. These controversial areas include venous thromboembolism patients with: heparin resistance, renal insufficiency, morbid obesity, cancer, antiphospholipid antibody syndrome, recurrent thrombosis despite appropriate anticoagulation, and patients with unprovoked VTE who may or may not benefit from thrombophilia testing. This review summarizes the current data for these special patient populations with venous thromboembolism and provides our recommendations for management.
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Affiliation(s)
- Matthew T Rondina
- The University of Utah Health Sciences Center, Department of Internal Medicine, Salt Lake City, UT 84132, USA.
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36
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Abstract
This study concerned the developmental regulation of wall-localized, hydroxyproline-containing proteins in maize tissues and organs. Silk and pericarp cell walls contained more peptidyl hydroxyproline than did walls of any vegetative tissue, although all tissues and organs accumulated these proteins as they matured. In many tissues, hydroxyproline-rich proteins are first associated with the wall in a soluble form before being insolubilized through covalent attachment to the matrix. Because hydroxyproline was more soluble earlier than later in development, it appears that insolubilization was occurring in maize tissues and organs as well. Tissue prints reacted with an anti-extensin antibody gave positive results, indicating the presence of a soluble form of this common hydroxyproline-rich glycoprotein (HRGP). Silk and pericarp cells actively synthesized this extensin from abundant transcripts. In vegetative tissues, extensin transcripts were somewhat more abundant in seedlings than in pre-anthesis or mature plants, but levels were much lower than in silk and pericarp. Southern blots of maize genomic DNA indicated that these extensin transcripts are encoded by a small multigene family. Potential roles for extensin in reproductive/protective tissues versus the embryo or vegetative tissues are suggested.
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Affiliation(s)
- E E Hood
- Department of Biology, Utah State University, Logan 84322-5305
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O'Donohue TL, Miller RL, Pendleton RC, Jacobowitz DM. Demonstration of an endogenous circadian rhythm of alpha-melanocyte stimulating hormone in the rat pineal gland. Brain Res 1980; 186:145-55. [PMID: 7357442 DOI: 10.1016/0006-8993(80)90261-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
alpha-Melanocyte stimulating hormone (alpha-MSH) has been identified and characterized in the rat pineal gland by a combination of immunochemical and high pressure liquid chromatographic techniques. The immunoreactivity in pineal extracts was separated into two chromatographic components. The major component had a retention time identical to that of alpha-MSH while the minor component eluted just slightly before standard alpha-MSH. Male rats maintained in a 12 h photoperiod demonstrated a marked circadian rhythm in pineal alpha-MSH concentration. Concentrations that peaked at 07.00 h, 1 h after the lights were turned on, were greater than 5 times the nadir which occurred at 01.000 h. Animals house in chronic dark for 7 days maintained the diurnal variation of alpha-MSH concentrations. However, in chronically dark housed rats, the peak shifted to 05.000 h and was greater than 10 times the nidir of this rhythm and approximately 4 time the peak at 07.00 in alternating light/dark conditions. Rats exposed to chronic light for 7 days maintained a pineal alpha-MSH rhythm although the amplitude of the peak was significantly decreased compared to the rhythm in animals housed in alternating light/dark conditions. Neither hypophysectomy nor superior cervical ganglionectomy had any effect on the alpha-MSH rhythm. Lesion of the arcuate nucleus, the major source of alpha-MSH-containing nerves in the brain, did not significantly affect pineal alpha-MSH concentrations. These data demonstrate a circadian alpha-MSH rhythm in the rat pineal and suggest an alpha-MSH involvement in the rhythmic processes of the pineal gland.
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O'Donohue TL, Miller RL, Pendleton RC, Jacobowitz DM. A diurnal rhythm of immunoreactive alpha-melanocyte-stimulating hormone in discrete regions of the rat brain. Neuroendocrinology 1979; 29:281-7. [PMID: 574621 DOI: 10.1159/000122934] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A significant diurnal variation in alpha-melanocyte stimulating hormone (alpha-MSH) concentrations was observed in discrete regions of the rat brain. During the 12 h light: 12 h dark cycle, alpha-MSH concentrations in each case were highest during the light period and lowest during the dark period. At 09.00 h, 3 h after lights were turned on, the peak alpha-MSH concentration occurred in the median eminence, the arcuate and dorsomedial hypothalamic nuclei and the periventricular thalamic nucleus. The paraventricular and anterior hypothalamic nuclei had highest alpha-MSH concentrations at 13.00 h. In the medial preoptic nucleus, the peak alpha-MSH concentrations appeared at 17.00 h. These changes in alpha-MSH content may reflect an alpha-MSH role in circadian variations in behavioral and neuroendocrine processes.
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Pendleton RC, Lloyd RD. Zirconium-95 in Utah vegetation produced during the 1966 growing season. Radiol Health Data Rep 1970; 11:277-81. [PMID: 5433818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Pendleton RC, Lloyd RD. Environmental levels of radioactivity in Utah following Operation Pinstripe. Radiol Health Data Rep 1970; 11:65-7. [PMID: 5434965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lloyd RD, Mays CW, Pendleton RC, Clark DO. A comparison of the cesium-137 content of milk and people from 19 dairy farms in Utah. Radiol Health Data Rep 1969; 10:427-33. [PMID: 5394698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lloyd RD, Zundel WS, Mays CW, Wagner WW, Pendleton RC, Aamodt RL, Tyler FH. Short caesium half-times in patients with muscular dystrophy. Nature 1968; 220:1029-31. [PMID: 5701838 DOI: 10.1038/2201029a0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Lloyd RD, Pendleton RC, Downard TR. Radioactivity within a tunnel in granitic rock. Health Phys 1968; 15:274-276. [PMID: 5676169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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47
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Abstract
Nuclear explosions in Nevada in July 1962 caused an average intake of about 58,000 picocuries of I(131) and a peak intake of 800,000 picocuries of I(131) by Utah residents consuming one liter of milk per day. Corresponding infant thyroid doses were about 1 rad (average) and 14 rad (peak).
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49
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Pendleton RC, Smart EW. A Study of the Food Relations of the Least Chub, Iotichthys phlegethontis (Cope), Using Radioactive Phosphorus. J Wildl Manage 1954. [DOI: 10.2307/3797718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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