High Incidence of Patients Lost to Follow-up After Venous Thromboembolism Diagnosis—Identifying an Unmet Need for Targeted Transition of Care

Objectives Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. Methods This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. Results During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home ( p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1–3.6, p = 0.03) as opposed to home. Conclusions Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

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Transition of Care for Pediatric and Adult Patients with Venous Thromboembolism in the American Thrombosis Hemostasis Network

Blood ◽

10.1182/blood-2018-99-117533 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4711-4711

Author(s):

Madhvi Rajpurkar ◽

Maura Malone ◽

Jim Munn ◽

Julie Jaffray ◽

Crystal Watson ◽

...

Keyword(s):

Quality Improvement ◽

Venous Thromboembolism ◽

Research Funding ◽

Pediatric Patients ◽

Anticoagulation Therapy ◽

Adult Patients ◽

First Episode ◽

Transition Of Care ◽

Significant Difference

Abstract Background Venous thromboembolism (VTE) is the third leading cause of cardiovascular morbidity and mortality worldwide in adults and is increasingly seen in children. Optimal transition of care (TOC) from the inpatient to the outpatient setting may lead to improved outcomes for patients with VTE. Although several examples of TOC for patients with VTE exist, this project (ATHN 4: Transition of Care for Patients with VTE) is the first to create a uniform TOC model in the U.S that includes both pediatric and adult patients. The aim of this study was to improve the transition of care of adult and pediatric patients discharged on an anticoagulant after a first episode of VTE and evaluate patient/parent understanding and adherence to anticoagulation therapy-related instructions at seven and 30 days after hospital discharge. Methods Pediatric and adult hospitalized patients with a first episode of VTE requiring anticoagulation therapy were eligible to participate in ATHN 4, a multi-center quality improvement (QI) project conducted by the American Thrombosis and Hemostasis Network (ATHN). The project has two phases: a pre-intervention (PI) phase with no change in standard TOC practice, and a QI intervention phase consisting of enhanced education with standardized Comprehensive Discharge Instruction Modules (CDIM) for each anticoagulant. Demographics, disease, treatment characteristics, and outcomes were collected. Knowledge and feedback questionnaires were administered at 30 days post-discharge. Adult and pediatric data from the PI phase are presented. Results Complete data were submitted for 188 (91%) patients who were enrolled in the PI phase between May 2016 and March 2017 (Table 3). Results show that 73 (39%) were under 18 years of age, 90 (48%) were female, and 156 (83%) were non-Hispanic. A significant difference (p<0.001) in the location of the first VTE was noted among the pediatric and adult patients (Table 4). Approximately 66% (n=48) of the pediatric patients had a DVT, compared to 30% (n=34) of the adult patients. There were more adults with PE as compared to pediatric patients(43% vs. 3%). Adult and pediatric patients differ substantially (p <0.001) with respect to anticoagulant prescriptions. Pediatric patients were more likely to be prescribed Enoxaparin at discharge compared to adults (86% vs. 21%). Additionally, a significantly larger proportion of adult compared to pediatric patients was prescribed Warfarin (17% vs. 3%). Direct oral anticoagulants (DOACs) were mainly prescribed in the adult patients: Apixaban (24% vs. 0%) and Rivaroxaban (18% vs. 3%) compared to the pediatric patients. Based on the responses provided by the patients or guardians (for pediatric patients) during the Day 30 follow-up, there was almost an equal distribution among pediatric and adult patients who by clinical assessment were determined to have correctly taken the prescribed anticoagulant between the time of discharge and follow-up (98.6% of pediatrics and 97.4% of adults). Conclusions Our quality improvement study shows that the majority of pediatric and adult patients correctly took the anticoagulation medication prescribed to them at discharge for at least a month. Majority of pediatric patients presented with a DVT while PE was the most common presentation in adult patients. Enoxaparin and Apixaban were the most commonly prescribed anticoagulants to pediatric and adult patients, respectively. Factors affecting anticoagulation adherence and outcomes in these patients are currently being analyzed. Disclosures Rajpurkar: Bristol Myers Squibb: Research Funding; Shire: Honoraria; HEMA biologics: Honoraria; Pfizer: Honoraria, Research Funding; Novonordisk: Honoraria. Jaffray:Octapharma: Consultancy; CSL Behring: Consultancy, Research Funding; Bayer: Consultancy.

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Lost to Follow-Up

Skin & Allergy News ◽

10.1016/s0037-6337(09)70596-0 ◽

2009 ◽

Vol 40 (12) ◽

pp. 13

Author(s):

ALAN ROCKOFF

Keyword(s):

Lost To Follow Up

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Predicting the risk of becoming lost to follow-up in a lifestyle weight-loss intervention

PsycEXTRA Dataset ◽

10.1037/e546872013-106 ◽

2013 ◽

Author(s):

Danielle M. Lespinasse ◽

Kristen E. Medina ◽

Stacey N. Maurer ◽

Samantha A. Minski ◽

Renee T. Degener ◽

...

Keyword(s):

Weight Loss ◽

Weight Loss Intervention ◽

Lost To Follow Up

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Post Discharge Clinically Overt Venous Thromboembolism in Orthopaedic Surgery Patients with Negative Venography -an Overview Analysis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650681 ◽

1996 ◽

Vol 76 (06) ◽

pp. 0887-0892 ◽

Cited By ~ 32

Author(s):

Serena Ricotta ◽

Alfonso lorio ◽

Pasquale Parise ◽

Giuseppe G Nenci ◽

Giancarlo Agnelli

Keyword(s):

Venous Thromboembolism ◽

Orthopaedic Surgery ◽

Diagnostic Methods ◽

Future Research ◽

Post Discharge ◽

Pharmacological Prophylaxis ◽

Vein Thrombosis ◽

Overview Analysis ◽

Major Orthopaedic Surgery

SummaryA high incidence of post-discharge venous thromboembolism in orthopaedic surgery patients has been recently reported drawing further attention to the unresolved issue of the optimal duration of the pharmacological prophylaxis. We performed an overview analysis in order to evaluate the incidence of late occurring clinically overt venous thromboembolism in major orthopaedic surgery patients discharged from the hospital with a negative venography and without further pharmacological prophylaxis. We selected the studies published from January 1974 to December 1995 on the prophylaxis of venous thromboembolism after major orthopaedic surgery fulfilling the following criteria: 1) adoption of pharmacological prophylaxis, 2) performing of a bilateral venography before discharge, 3) interruption of pharmacological prophylaxis at discharge in patients with negative venography, and 4) post-discharge follow-up of the patients for at least four weeks. Out of 31 identified studies, 13 fulfilled the overview criteria. The total number of evaluated patients was 4120. An adequate venography was obtained in 3469 patients (84.1%). In the 2361 patients with negative venography (68.1%), 30 episodes of symptomatic venous thromboembolism after hospital discharge were reported with a resulting cumulative incidence of 1.27% (95% C.I. 0.82-1.72) and a weighted mean incidence of 1.52% (95% C.I. 1.05-1.95). Six cases of pulmonary embolism were reported. Our overview showed a low incidence of clinically overt venous thromboembolism at follow-up in major orthopaedic surgery patients discharged with negative venography. Extending pharmacological prophylaxis in these patients does not appear to be justified. Venous thrombi leading to hospital re-admission are likely to be present but asymptomatic at the time of discharge. Future research should be directed toward improving the accuracy of non invasive diagnostic methods in order to replace venography in the screening of asymptomatic post-operative deep vein thrombosis.

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Lost to follow-up in classic congenital adrenal hyperplasia: a case report

Endocrine Abstracts ◽

10.1530/endoabs.63.ep12 ◽

2019 ◽

Author(s):

Costa Cristiana Gomes da ◽

Tania Matos ◽

Vale Sonia do

Keyword(s):

Case Report ◽

Congenital Adrenal Hyperplasia ◽

Adrenal Hyperplasia ◽

Classic Congenital Adrenal Hyperplasia ◽

Lost To Follow Up

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Respiratory Complications in Outpatient Endoscopy with Endoscopist-Directed Sedation

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.233.kf1 ◽

2014 ◽

Vol 23 (3) ◽

pp. 255-259 ◽

Cited By ~ 11

Author(s):

Kilian Friedrich ◽

Sabine G. Scholl ◽

Sebastian Beck ◽

Daniel Gotthardt ◽

Wolfgang Stremmel ◽

...

Keyword(s):

Antibiotic Treatment ◽

Respiratory Infection ◽

Endoscopic Procedure ◽

Shortness Of Breath ◽

Respiratory Complications ◽

Endoscopic Procedures ◽

Increased Risk ◽

High Incidence ◽

Respiratory Complaints

Background & Aims: Respiratory complications represent an important adverse event of endoscopic procedures. We screened for respiratory complications after endoscopic procedures using a questionnaire and followed-up patients suggestive of respiratory infection.Method: In this prospective observational, multicenter study performed in Outpatient practices of gastroenterology we investigated 15,690 patients by questionnaires administered 24 hours after the endoscopic procedure.Results: 832 of the 15,690 patients stated at least one respiratory symptom after the endoscopic procedure: 829 patients reported coughing (5.28%), 23 fever (0.15%) and 116 shortness of breath (SOB, 0.74%); 130 of the 832 patients showed at least two concomitant respiratory symptoms (107 coughing + SOB, 17 coughing + fever, 6 coughing + coexisting fever + SOB) and 126 patients were followed-up to assess their respiratory complaints. Twenty-nine patients (follow-up: 22.31%, whole sample: 0.18%) reported signs of clinically evident respiratory infection and 15 patients (follow-up: 11.54%; whole sample: 0.1%) received therefore antibiotic treatment. Coughing or vomiting during the endoscopic procedure resulted in a 156.12-fold increased risk of respiratory complications (95% CI: 67.44 - 361.40) and 520.87-fold increased risk of requiring antibiotic treatment (95% CI: 178.01 - 1524.05). All patients of the follow-up sample who coughed or vomited during endoscopy developed clinically evident signs of respiratory infection and required antibiotic treatment while this occurred in a significantly lower proportion of patients without these symptoms (17.1% and 5.1%, respectively).Conclusions: We demonstrated that respiratory complications following endoscopic sedation are of comparably high incidence and we identified major predictors of aspiration pneumonia which could influence future surveillance strategies after endoscopic procedures.

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