VTE Prophylaxis Across the Continuum of Care in US Orthopedic Surgery Patients.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2097-2097
Author(s):  
Alpesh Amin ◽  
Jay Lin ◽  
Amy Ryan
Keyword(s):  
At Risk ◽  
Orthopedic Surgery ◽  
Research Funding ◽  
Significant Risk ◽  
Post Discharge ◽  
Vte Prophylaxis ◽  
Individual Patient Level ◽  
Hip Fracture Surgery ◽  
Major Orthopedic Surgery ◽  
Patients At Risk

Abstract Abstract 2097 Poster Board II-74 Background: Patients who undergo major orthopedic surgery are at significant risk of developing VTE. As 40-60% of orthopedic surgery patients develop VTE in the absence of thromboprophylaxis, evidence-based guidelines recommend pharmacological VTE prophylaxis in all patients without contraindications. As the risk of VTE persists beyond discharge in these patients, the use of LMWH and warfarin post-discharge is both suitable and recommended. However, a lack of awareness and education often leads to an absence of VTE prophylaxis post-discharge. This analysis evaluated in-hospital and post-discharge VTE prophylaxis patterns for US orthopedic surgery patients. Methods: Premier's Perspective” inpatient data were cross-matched at the individual patient level with Ingenix LabRx® outpatient data from the I3 database (January 2005-December 2007) to assess VTE prophylaxis patterns in major orthopedic surgery (total knee arthroplasty, total hip arthroplasty, hip fracture surgery) patients at risk of VTE (according to the American College of Chest Physicians 2004 guidelines) and with no contraindications for anticoagulation. Inpatients were assessed for the anticoagulant received in-hospital and were followed post-discharge to assess their outpatient prophylaxis use. Drug utilization and clinical practice patterns during and within 30 days after hospitalization were collected and compared descriptively between groups. Results: Of the 3,311 orthopedic surgery discharges at risk of VTE and included in this analysis, only 295 (8.9%) did not receive any anticoagulation at all. Of the remaining 3,016 (91.1%) discharges that did receive anticoagulation, 1,061 (35.2%) received enoxaparin, 1,028 (34.1%) received warfarin, and the remaining 927 (30.7%) received other or combination prophylaxis. However, after discharge only 1,800 (54.4%) of all patients received prophylaxis, with the majority receiving warfarin (1,028, 57.1%). The remaining 1,511 (45.6%) received no outpatient prophylaxis (Table). Conclusion: This analysis presents both inpatient and outpatient VTE prophylaxis patterns in real-world orthopedic surgery patients that are at risk of VTE. Although the rate of prophylaxis was high in inpatients, approximately half of all patients had no prophylaxis post-discharge. Further efforts to improve VTE prevention in discharged orthopedic surgery patients are required. Disclosures: Amin: sanofi-aventis: Research Funding, Speakers Bureau, The authors received editorial/writing support in the preparation of this abstract funded by sanofi-aventis U.S., Inc. . Lin:sanofi-aventis: Employment. Ryan:sanofi-aventis: Research Funding.

VTE Prophylaxis Across the Continuum of Care in US Medical Patients at Risk of Venous Thromboembolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1386-1386
Author(s):  
Alpesh Amin ◽  
Jay Lin ◽  
Amy Ryan
Keyword(s):  
At Risk ◽  
Research Funding ◽  
Medical Patients ◽  
Post Discharge ◽  
Vte Prophylaxis ◽  
Individual Patient Level ◽  
Patients At Risk ◽  
The Individual ◽  
Severe Lung Disease ◽  
The Continuum

Abstract Abstract 1386 Poster Board I-408 Background: Medical patients with chronic medical illnesses are often at risk of VTE both in-hospital and post-discharge. However, although injectable prophylaxis options are available and suitable for providing in-hospital and post-discharge prophylaxis, there is often a lack of continuity in VTE post-discharge prophylaxis. This analysis evaluated in-hospital and post-discharge VTE prophylaxis patterns for US medical patients. Methods: Premier's Perspective™ inpatient data were cross-matched at the individual patient level with Ingenix LabRx® outpatient data from the I3 database (January 2005-December 2007) to assess VTE prophylaxis patterns in medical patients (cancer without surgery, heart failure, severe lung disease, infectious disease) at risk of VTE (according to the American College of Chest Physicians 2004 guidelines) and with no contraindications for anticoagulation. Inpatients were assessed for any anticoagulation received in-hospital and were followed post-discharge to assess their outpatient prophylaxis use. Drug utilization and clinical practice patterns during and within 30 days after hospitalization were collected and compared descriptively between groups. Results: Of the 9,675 medical discharges at risk of VTE and included in this analysis, 6,185 (63.9%) did not receive any anticoagulation at all. Of the remaining 3,490 (36.1%) discharges that did receive anticoagulation, 2,045 (58.6%) received enoxaparin and 1,044 (29.9%) received unfractionated heparin (UFH) (Table). After discharge, 98.2% of all patients did not receive any prophylaxis within the following 30 days. Only 174 (1.8%) discharges received outpatient prophylaxis, with 67.8% receiving warfarin alone and 18.4% receiving enoxaparin and warfarin (Table). Conclusion: This analysis presents both inpatient and outpatient VTE prophylaxis patterns in real-world medical patients that are at risk of VTE. Nearly 64% of patients received no inpatient VTE prophylaxis, and less than 2% received outpatient prophylaxis. Further efforts to improve VTE prevention in hospitalized patients are required, with particular emphasis needed on the transition to outpatient prophylaxis. Disclosures: Amin: sanofi-aventis: Research Funding, Speakers Bureau, The authors received editorial/writing support in the preparation of this abstract funded by sanofi-aventis U.S., Inc.. Lin: sanofi-aventis: Employment. Ryan: sanofi-aventis: Research Funding.

Impact of Surgery Type and Co-Morbidities on Venous Thromboembolism prophylaxis Practices in Patients Undergoing Major Surgical Procedures in Acute Care Hospitals Worldwide: A Subanalysis of Data from the ENDORSE Survey

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 171-171 ◽  
Author(s):  
Ajay K Kakkar ◽  
Alexander T Cohen ◽  
Victor F Tapson ◽  
Jean-Francois Bergmann ◽  
Samuel Z. Goldhaber ◽  
...  
Keyword(s):  
At Risk ◽  
Hip Replacement ◽  
Multivariable Analysis ◽  
Surgical Patients ◽  
Major Surgery ◽  
Vte Prophylaxis ◽  
Factors Associated ◽  
Major Orthopedic Surgery ◽  
Patients At Risk ◽  
To Receive

Abstract Introduction: Despite the publication of international consensus guidelines for the provision of venous thromboembolism (VTE) prophylaxis, the recent ENDORSE survey reported that 64% of patients admitted to surgical wards in hospitals worldwide are at risk for VTE, and of those only 59% received appropriate prophylaxis (Lancet2008;371:387–94). In this sub-analysis of ENDORSE data, we assess the provision of VTE prophylaxis according to surgery type, and evaluate the key factors associated with the decision to provide VTE prophylaxis to surgical patients. Methods: ENDORSE was a multinational, cross-sectional survey of patients admitted to medical and surgical wards in 358 hospitals across 32 countries (Lancet2008;371:387–94). VTE risk and prophylaxis use were assessed in evaluable patients according to the 2004 American College of Chest Physicians (ACCP) guidelines (Chest2004;126:338S–400S). Major surgery was grouped into the following categories: major orthopedic (hip replacement, knee replacement, hip fracture repair); abdominal/thoracic (colon/small bowel, rectosigmoid, gastric, hepatobiliary, thoracic); vascular; urological/gynecological; and other (curative arthroscopy, other orthopedic trauma, other surgeries). Independent factors associated with the use of ACCP-recommended prophylaxis in surgical patients at risk for VTE were evaluated using multivariable logistic regression analyses. Results: Of the 30,827 patients in surgical wards included in ENDORSE, 18,461 had undergone major surgery as of the date of the survey. Of these, 17,018 (92.2%) were considered to be at risk for VTE, although only 10,710 (58.0%) received ACCP-recommended types of VTE prophylaxis. The proportion of patients at risk for VTE and the use of ACCP-recommended prophylaxis varied according to surgery type (Table). Multivariable analysis confirmed that surgery type was the factor that was most strongly associated with the provision of ACCP-recommended VTE prophylaxis. Patients undergoing major orthopedic surgery were most likely to receive recommended VTE prophylaxis, with patients undergoing hip replacement surgery 6 times more likely to receive ACCP- prophylaxis (OR 6.2; 95% CI 5.0–7.9). Curative arthroscopy and rectosigmoid surgery were also strongly associated with the provision of ACCP-recommended prophylaxis: (OR 3.6; 95% CI 2.3–5.4 and OR 2.3; 95% CI 1.7–3.0, respectively). When surgery type was excluded from the multivariable analysis, obesity (OR 1.9; 95% CI 1.7–2.1), rheumatologic or inflammatory disease (OR 1.7; 95% CI 1.3– 2.2), and previous VTE (OR 1.7; 95% CI 1.3–2.1) were the clinical characteristics most strongly associated with the use of recommended VTE prophylaxis. Conclusion: The provision of ACCP-recommended VTE prophylaxis was primarily driven by the fact that patients underwent a major operation and rates of prophylaxis use varied substantially according to the type of surgery. Patients undergoing major orthopedic surgery are most likely to receive appropriate VTE prophylaxis, however up to 45% of at-risk patients undergoing non-orthopedic procedures do not receive ACCP-recommended prophylaxis. Surgery type was the most important factor associated with the decision to provide ACCP-recommended prophylaxis in surgical patients at risk for VTE. Table: Prevalence of VTE risk and use of ACCP-recommended prophylaxis according to surgery type. Surgery type N Patients at risk For VTE n (%) At-risk receiving ACCP-Recommended prophylaxisn (%) Major orthopedic 2300 2300 (100) 1979 (86.0) Abdominal/thoracic 5028 4527 (90.0) 3023 (66.8) Vascular 1038 946 (91.1) 676 (71.5) Urological/gynecological 2653 2344 (88.4) 1261 (53.8) Other 7442 6901 (92.7) 3771 (54.6)

Real-World VTE Prophylaxis Practices in US Orthopedic Surgery Patients: An Analysis of An Integrated Healthcare Database.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1075-1075
Author(s):  
Geno J Merli ◽  
Elisabetta Malangone ◽  
Jay Lin ◽  
Lee Stern
Keyword(s):  
Molecular Weight ◽  
Real World ◽  
Orthopedic Surgery ◽  
Research Funding ◽  
Average Length ◽  
Low Molecular Weight ◽  
Pharmacological Prophylaxis ◽  
Vte Prophylaxis ◽  
Major Orthopedic Surgery ◽  
Prophylaxis Therapy

Abstract Abstract 1075 Poster Board I-97 Introduction: Major orthopedic surgery patients are at high risk of venous thromboembolism (VTE), with a VTE incidence of 40-60% in patients that do not receive thromboprophylaxis. However, the incidence of VTE can be significantly reduced with the use of evidence-based thromboprophylaxis such as low-molecular-weight heparins (LMWH) and warfarin. Although prophylaxis is often provided in-hospital, there is frequently a break in the continuum of VTE prophylaxis on discharge, despite the applicability of LMWH or warfarin for outpatient prophylaxis. The purpose of this study is to describe real-world inpatient and outpatient pharmacological prophylaxis practices of patients undergoing major orthopedic surgery. Methods: Patients greater than 18 years of age in a large, vertically integrated Midwestern healthcare system (January 1995 to June 2008) and with a Current Procedural Terminology (CPT) code for predetermined knee and hip orthopedic surgeries were eligible for this study. Patients with atrial fibrillation or less than 18 months of continuous health plan enrollment (including a minimum of 1-year post-discharge) were excluded from the analyses. Prophylaxis therapy was assessed during the first year of follow-up and stratified by inpatient versus outpatient therapy. Characteristics of prophylaxis use, such as anticoagulation duration, prophylaxis type stratified by surgery, and mean INR were also examined. Results: A total of 2382 patients were included in the analysis, with 1393 (58.5%) undergoing total knee arthroplasty (TKA) and 989 (41.5%) undergoing total hip arthroplasty (THA). The average length of hospital stay was 4.7 days in TKA patients and 5.1 days in THA patients. When considering prophylaxis use, 72.7% of TKA patients received inpatient pharmacological prophylaxis alone, 12.5% received inpatient and outpatient pharmacological prophylaxis, 3.5% received only outpatient pharmacological prophylaxis and 11.3% received no pharmacological prophylaxis (Table). Similarly in THA patients, 73.2% received inpatient pharmacological prophylaxis alone, 12.4% received inpatient and outpatient pharmacological prophylaxis, 3.2% received only outpatient pharmacological prophylaxis and 10.9% received no pharmacological prophylaxis. In both TKA and THA patients, the most frequent inpatient prophylaxis therapy was low-molecular-weight heparin (90.6% and 85.6%, respectively). In those patients that received warfarin, the majority (67.9%) had a mean INR between 1 and 2 during the first 2 months. Conclusions: This analysis highlights the short duration of prophylaxis provided to US orthopedic surgery patients. Despite these patients having mean hospital stays of approximately 5 days and guidelines recommending a minimum of 10 days of prophylaxis for major orthopedic surgery patients, only approximately 15% of patients received outpatient prophylaxis. Disclosures: Merli: sanofi-aventis: Consultancy, Research Funding, Speakers Bureau, The authors received editorial/writing support in the preparation of this abstract funded by sanofi-aventis U.S., Inc.; AstraZeneca: Consultancy, Research Funding, Speakers Bureau; Boehringer Ingelheim: Research Funding; Bayer: Consultancy; Bacchus Scientific: Consultancy. Malangone:sanofi-aventis: Research Funding. Lin:sanofi-aventis: Employment. Stern:sanofi-aventis: Research Funding.

Fatal vascular outcomes following major orthopedic surgery

2005 ◽  
Vol 93 (05) ◽  
pp. 860-866 ◽  
Author(s):  
Joseph Caprini ◽  
Clifford Colwell ◽  
Simon Frostick ◽  
Sylvia Haas ◽  
Russell Hull ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Hip Fracture ◽  
Cohort Studies ◽  
Orthopedic Surgery ◽  
Fatal Pulmonary Embolism ◽  
Vascular Events ◽  
Hip Fracture Surgery ◽  
Major Orthopedic Surgery ◽  
Fracture Surgery ◽  
Overall Mortality

SummaryMajor orthopedic surgery is known to be associated with potentially serious arterial and venous vascular complications, although uncertainty exists about current event rates. Using electronic databases and investigator contact, we identified randomized and cohort studies reporting overall mortality and fatal vascular events. Where possible, studies reporting high autopsy rates (>60%) were examined. Pooled incidences were calculated from eligible studies. For Autopsy studies: Pooled overall mortality and fatal pulmonary embolism for patients undergoing elective hip and knee replacement without prophylaxis could not be calculated, while with prophylaxis they were 0.44% (95% confidence interval 0.02 to 0.87%) and 0.43% (0.01 to 0.85%). For patients undergoing hip fracture surgery, the corresponding rates without prophylaxis were 15.9% (14.5 to 17.3%) and 1.9% (1.4 to 2.4%). With prophylaxis, mortality and fatal pulmonary embolism rates were 8.5% (7.3 to 9.7%) and 1.0% (0.6 to 1.5%). Among Cohort studies: Pooled overall mortality and fatal pulmonary embolism for patients undergoing elective hip and knee replacement without prophylaxis were 0.93% (0.57 to 1.29%) and 0.36% (0.14 to 0.59%). For patients receiving prophylaxis (7 to 14 days), mortality and fatal pulmonary embolism were 0.57% (0.51 to 0.62%) and 0.18% (0.14 to 0.21%). Patients undergoing hip fracture surgery receiving prophylaxis had mortality and fatal pulmonary embolism rates of 3.2% (2.8 to 3.6%) and 0.30% (0 to 0.61%). Vascular events contributed towards approximately 50% of all deaths with similar proportions due to ischemic heart disease, cardiac failure and pulmonary embolism. In conclusion, although prophylaxis results in a reduction in overall mortality and fatal pulmonary embolism, vascular events continue to be a common cause of mortality.

scholarly journals Risk of Venous Thrombosis in Patients with Sickle Cell Trait after Orthopedic Surgery

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 417-417
Author(s):  
Jahnavi Gollamudi ◽  
Sadeer Al-Kindi ◽  
Petra Martin ◽  
Jane Little ◽  
Lalitha V. Nayak
Keyword(s):  
Logistic Regression ◽  
Sickle Cell ◽  
Orthopedic Surgery ◽  
Research Funding ◽  
Sickle Cell Trait ◽  
Knee Surgery ◽  
Orthopedic Procedures ◽  
Major Orthopedic Surgery ◽  
The Us ◽  
Hip And Knee Surgery

Abstract Introduction Sickle cell trait (SCT) is considered to confer a hypercoagulable state. Historically, venous thromboembolism (VTE, deep vein thrombosis and PE) rates for untreated patients after major orthopedic surgery (hip or knee replacement or hip fracture surgery) have been close to 4.3%, however with the introduction of post-op anticoagulation, the rates have been as low as 1.15%. Although guidelines exist regarding anticoagulation for up to 35 days after major orthopedic surgery, there are no specific recommendations for patients with SCT. The purpose of this retrospective study is to examine the rates of VTE after major orthopedic surgery in a cohort of patients with SCT. We hypothesize that rates of VTE would be higher in patients with SCT and the risk of VTE would persist beyond 35 days. Methods A commercial database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems representing a sixth of the US population, was queried for data, using Systematized Nomenclature of Medicine (SNOMED) clinical terms or codes. Cases were defined as patients with SCT who underwent major knee or hip surgery. Since a majority of the US population with SCT are African American (AA) patients, controls were defined as AA patients without SCT undergoing major orthopedic surgery. For the primary end point of VTE, only adult patients (≥18 years) were selected. Those with previous history of VTE, thrombophilia, malignant disease, antiphospholipid antibody syndrome and other hemoglobinopathies such as sickle cell disease were excluded. 30 and 90-day rates of VTE were recorded for both groups. Logistic regression models were used to adjust of confounding variables (defined a priori as age > 65 or< 65, smoking, gender and presence or absence of body mass index > 30). Of note, SCT is likely under-estimated due to incomplete diagnosis. Rates or proportions were compared using Chi-squared testusing Medcalc software (2018). Logistic regression analysis was done using Statistical Package for Social Sciences (SPSS, version 21, IBM Corp, Armonk, NY). P< 0.05 was considered statistically significant. Results A total of 1360 major orthopedic surgeries in patients with SCT and 74040 surgeries in non-SCT patients were identified. 30 and 90-day VTE for SCT patients undergoing major orthopedic surgery was 9.7% each. 30 and 90 day VTE for non-SCT patients undergoing major hip and knee surgery were 5.9 % and 6.4 % respectively. The difference in 30-day and 90-day VTE rates between the SCT and non-SCT group was statistically significant (30 day VTE difference 3.1%, 95% CI 1.6650-4.7569, p < 0.001; 90 day VTE difference=3.6%; 95% CI 2.1658-5.2562, p= <0.001). The rates of anticoagulant dispensation (oral Xa inhibitors, enoxaparin or warfarin) after surgery were 56% and 46% in SCT and non-SCT group respectively (difference = 10%, 95% CI 7.32-12.64, p <0.001). Despite the higher proportion of patients prescribed for anticoagulants in the SCT population, there was still a higher 30 and 90-day VTE rate in that group. Compliance to anticoagulation and mortality from VTE could not be assessed in this study. Logistic regression of risk factors associated with risk of VTE revealed age over 65 years of age, female gender, active smoking status, obesity (BMI >30), and presence of sickle cell trait were all significantly associated with increased risk of both 30 and 90 day VTE post major orthopedic surgery. Please see Table 1 and 2 for further details. Conclusion Our study represents real life data outside of a clinical trial. We found that patients with SCT who underwent major hip and knee surgery had an increased 30 and 90-day VTE rates compared to non-SCT patients undergoing the same procedures. Overall, this cohort of AA patients had VTE rates higher than that were described in literature. Of note, AA patients overall are at a higher risk of VTE than are their Caucasian counterparts. The results from the study seem to suggest a role for extended prophylaxis in people with SCT who are undergoing orthopedic procedures, and warrants further study. Disclosures Little: Doris Duke Charitable Foundations: Research Funding; NHLBI: Research Funding; PCORI: Research Funding; Hemex: Patents & Royalties: Patent, no honoraria.

Assessing adherence to the American College of Chest Physicians’ (ACCP) recommendations for thromboprophylaxis in hospitalized cancer patients

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 9047-9047
Author(s):  
A. N. Amin ◽  
S. A. Stemkowski ◽  
J. Lin ◽  
G. Yang
Keyword(s):  
Colorectal Cancer ◽  
At Risk ◽  
Cancer Patients ◽  
Significant Risk ◽  
Minimum Length ◽  
Cancer Type ◽  
Specific Recommendation ◽  
Inclusion Criteria ◽  
Vte Prophylaxis ◽  
Cancer Types

9047 Background: This study evaluates whether clinicians are providing appropriate VTE prophylaxis to at-risk surgical and non- surgical cancer patients in accordance with ACCP guidelines. Methods: Premier's inpatient administrative data were used to assess VTE prophylaxis rates in fourteen cancer types. Patients age 40 or older, with a minimum length of stay of six days, and no contraindications for anti-coagulation were included in the study. Two rates were determined; the rate of discharges receiving any level of anticoagulation and the rate of patients receiving appropriate prophylaxis by comparing daily use of anti-coagulants and compression devices, dosage, and prophylaxis duration with ACCP recommendations. The 6th guidelines were used due to their release prior to the study period. Rates based on the 7th guidelines were calculated for the same patient cohort to assess how the revised guidelines affect our findings. Trends were assessed by comparing prophylaxis rates by quarter. Results: 72,391 discharges from 225 hospitals between January 2002 and September 2005 met the inclusion criteria. 29% of all at-risk cancer discharges received the recommended prophylaxis regimen. Rates varied by cancer type ranging from 18.7% in prostate to 36.3% in colorectal cancer discharges. 55% did not receive any anti-coagulation prophylaxis, 9.5% received insufficient dosage and 5.8% did not receive prophylaxis for the appropriate duration. The appropriate VTE prophylaxis rate is higher for surgical cancer than for non-surgical cancer discharges (32.3% vs. 27.7%). Trends suggest a slight increase in appropriate prophylaxis rates for all types of cancer discharges. Appropriate prophylaxis rates based on 7th guidelines are lower than rates based on the 6th guidelines due to the more specific recommendation in the 7th guidelines. Conclusions: Cancer patients are known to have significant risk for VTE, yet VTE prophylaxis for at-risk non-surgical cancer patients in hospitals is not optimal. Rates for surgical cancer patients were only slightly higher. Using the 7th recommendations results in lower prophylaxis rates. More effort is required to increase awareness of the ACCP recommendations for thromboprophylaxis in cancer patients. No significant financial relationships to disclose.

Cost of Major Bleeding Following Major Orthopedic Surgery.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 4061-4061
Author(s):  
Gerry Oster ◽  
Montserrat Vera-Llonch ◽  
May Hagiwara
Keyword(s):  
Major Bleeding ◽  
Orthopedic Surgery ◽  
Postoperative Bleeding ◽  
Hospital Charges ◽  
Vte Prophylaxis ◽  
Fatal Bleeding ◽  
Major Orthopedic Surgery ◽  
Baseline Characteristics ◽  
The Cost ◽  
The Impact

Abstract Rationale . The risk of major bleeding in major orthopedic surgery (MOS) patients who receive antithrombotics as prophylaxis against venous thromboembolism (VTE) may be higher for some agents than others. The cost of this complication is unknown. Objective . To assess the impact of major bleeding following MOS on length of stay (LOS) and inpatient charges. Methods . Using a database with information on ~750,000 admissions annually to 100+ US acute-care hospitals (MQProfile, Cardinal Information Corp.), we identified all patients who underwent MOS between 1/1/98 and 12/13/00. We stratified patients according to whether or not they experienced major postoperative bleeding prior to hospital discharge, defined as: (a) fatal bleeding; (b) nonfatal bleeding at critical site; (c) re-operation due to bleeding; and (d) overt bleeding with bleeding index (BI) ≥ 2, where BI = number of blood units transfused plus pre-bleeding minus post-bleeding hemoglobin (g/dL) values. LOS and total inpatient charges were compared between patients with and without major bleeding. Results . 23,518 patients were identified who underwent MOS. Incidence of major bleeding was 2.6%. In multivariate analyses controlling for differences in baseline characteristics between patients with and without major bleeds, adjusted mean LOS was 1.8 days longer (95% CI: 1.5, 2.0) among the former (6.1 days vs 4.3 days for those without bleeds); adjusted mean total inpatient charges were $7,593 higher (95% CI: $6,622, $8,646) ($25,669 vs $18,076). Conclusion . Major bleeding following MOS significantly increases LOS and hospital charges. The cost of major bleeding following MOS should factor into choice of VTE prophylaxis.

Comparison of the 2-Year Clinical Outcomes of VTE Prophylaxis Options in Medical Patients at Risk of VTE.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1876-1876
Author(s):  
Steven B. Deitelzweig ◽  
Jay Lin ◽  
Josh Benner ◽  
Russ Becker
Keyword(s):  
At Risk ◽  
Adverse Events ◽  
Unfractionated Heparin ◽  
Clinical Outcomes ◽  
Significant Risk ◽  
Decision Analytic Model ◽  
Chain Model ◽  
Medical Patients ◽  
Model Based ◽  
Patients At Risk

Abstract Background: Hospitalized medical patients are at significant risk of venous thromboembolism (VTE). Although evidence-based guidelines exist which provide recommendations for thromboprophylaxis in hospitalized medical patients, the optimum regimen for prophylaxis is not clear. We have therefore created a model, based on established literature, which examines the 2-year clinical outcomes following no prophylaxis, thromboprophylaxis with unfractionated heparin (UFH), or thromboprophylaxis with low-molecular-weight heparin (LMWH) in medical patients at risk of VTE. Methods: A decision-analytic model was developed that replicates and extends an existing, published VTE model (McGarry et al. Am J Manag Care.2004;10:632–42) from 30 days to 2 years. Hypothetical cohorts of 10,000 medically ill patients at risk of VTE (according to MEDENOX criteria) were assembled, using a Markov chain model with resampling, to compare the rates of primary VTE events and related outcomes at 90 days and VTE complications and recurrent events at 2 years. Clinical outcomes were estimated from published clinical trial and observational data, and compared between three interventions, namely no prophylaxis, UFH, and the LMWH enoxaparin. Outcomes included in the analysis were clinical or venographically detected primary VTE, major and minor bleeds, asymptomatic or symptomatic heparin-induced thrombocytopenia, and death within the first 90 days, as well as VTE recurrence, post-thrombotic syndrome, pulmonary hypertension, and death within 2 years. Sensitivity and threshold analyses were performed to test the general applicability of the model. The simulation model was run using TreeAge software (Williamstown, USA). Results: VTE rates and death were the lowest in the enoxaparin prophylaxis cohort, followed by the UFH and no prophylaxis cohorts respectively (Table 1). Adverse events were lowest in the no prophylaxis group, followed by the enoxaparin group and the UFH group (Table 1). Conclusion: In this Markov model, based on robust data from clinical trials and observational studies, prophylaxis with enoxaparin reduced VTE occurrence and mortality over two years when compared with no prophylaxis or UFH prophylaxis in hospitalized medical patients at risk of VTE. Enoxaparin was also associated with a reduced incidence of adverse events when compared with UFH. Table 1. Two-year outcomes in simulated cohorts of hospitalized medical patients at risk of VTE Outcome (n) Enoxaparin (n=10,000) Unfractionated heparin (n=10,000) No prophylaxis (n=10,000) VTE at 2 years 683 791 1787 DVT 545 633 1426 PE 138 158 361 Death 1573 1600 1745 Adverse events at 90 days 364 725 314 Minor bleed 285 510 244 Major bleed 65 116 55 Asymptomatic HIT 6 45 7 Symptomatic HIT 8 54 8

Defining the Risk: Benefit Ratio of Venous Thromboembolism (VTE) Prophylaxis in Hospitalized Cancer Patients

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 627-627 ◽  
Author(s):  
Dana E Angelini ◽  
Todd Greene ◽  
Julie N Wietzke ◽  
Scott A Flanders ◽  
Suman L. Sood
Keyword(s):  
Platelet Count ◽  
High Risk ◽  
Cancer Patients ◽  
Research Funding ◽  
Hospital Medicine ◽  
General Medicine ◽  
Number Needed To Treat ◽  
Medical Patients ◽  
Post Discharge ◽  
Vte Prophylaxis

Abstract Introduction: VTE affects 1.6-1.8/1000 hospitalized patients per year; active cancer increases the rate of VTE 6-fold. Despite the high risk of VTE, studies show cancer patients receive inpatient VTE prophylaxis at a lower rate than general medical patients. In addition, VTE prophylaxis is often held for a platelet value of <50x109/L, despite a lack of evidence. Current recommendations for all inpatients with cancer (and no contraindication to blood thinners) are to receive prophylactic anticoagulation, regardless of an increased bleeding tendency in this population. A formal risk:benefit ratio of inpatient VTE prophylaxis for cancer patients has not been evaluated to date. Methods: The Michigan Hospital Medicine Safety Consortium, a 49 hospital quality collaborative, has prospectively collected data on VTE risk factors and outcomes in medical patients > 18 years of age. Exclusion criteria include surgical patients, pregnancy, admission to the ICU or for palliative care, therapeutic anticoagulation, diagnosis of acute thrombus, history of VTE within 6 months, and length of stay < 2 days. We compared rates of VTE prophylaxis, bleeding and new VTE between cancer and general medicine patients who were eligible for prophylaxis (i.e. no contraindications including active bleed within 3 months, coagulopathy, or high risk brain metastasis). Student's t-test was used for continuous variables and chi-square for categorical data. Logistic regression was used to calculate odds ratio (OR). The number needed to treat and number needed to harm were used to derive a risk:benefit ratio. Results: Between 7/2012-7/2015, 86,634 admissions were captured in the cohort; 70,086 were eligible for VTE prophylaxis and included in this analysis. 22% of cases had a diagnosis of cancer. Table 1. Demographics on Admission Cancer (n= 15,166), % General Medicine (n=54,920), % p Race (Caucasian) 82.3 74.3 <0.001 Age mean yrs (SD) 72.5 (14.4) 63.7 (18.8) <0.001 Gender (female) 53.6 56.5 <0.001 Central Line 17.8 4.1 <0.001 History of VTE 7.6 5.3 <0.001 Caprini risk score ≥ 5 88.1 35.8 <0.001 Charleston Index mean (SD) 5.1 (2.5) 2.1 (2.0) <0.001 Ever Smoked 59.6 56.3 <0.001 Obese 29.3 37.1 <0.001 Surgery w/in 30 days 3.6 2.1 <0.001 Trauma w/in 30 days 0.3 0.4 0.01 Of cancer admissions, 89.5% had solid tumors, 13.5% hematologic malignancies, 3.4% both and 20% metastatic disease. Active treatment for cancer was delivered <6 months from index admission in 32.1%, within 6-12 mo in 3.2%, >12 mo in 44.4% and no treatment or unknown in 20.3%. When compared to general medical admissions, cancer admissions were more likely to receive VTE prophylaxis (72.16% vs 69.21%, p<0.001), and have a new VTE out to 90 days post discharge despite prophylaxis (0.91% vs 0.45%, p<0.001, unadjusted OR 2.07 (95% CI 1.6-2.7)). There was no difference in VTE rate with regard to platelet count in cancer cases (0.43% for plt < 50 vs 1.08% for plt ≥ 50, p=0.10). Among all patients receiving VTE prophylaxis, bleeding was more common in cancer cases (major bleeding 0.84% vs 0.58%, p=0.005; minor bleeding 1.80% vs 1.36%, p=0.002). Among cancer cases, bleeding rates were higher in patients with platelet <50 vs ≥ 50 (major bleed 4.86% vs 1.88%, p<0.001; minor bleed 2.88% vs 1.7%, p=0.04). Table 2. The Number Needed to Treat (NNT) to Prevent One VTE During Admission or 90 Days Post Discharge and Number Needed to Harm (NNH) to Cause One Major Bleed During Admission with Risk:Benefit Ratio (NNH:NNT) General Medicine Cancer NNT 1428 NNT 1000 NNH 2500 NNH 277.9 NNH:NNT 1.75 NNH:NNT 0.28 Conclusions: In this prospective inpatient cohort, we compared general medicine to cancer cases and found cancer admissions received VTE prophylaxis at a higher rate. This is different than previously reported data, likely due to the exclusion of patients with contraindications to prophylaxis. However, despite prophylaxis, cancer patients had a higher rate of VTE during admission and 90 days post discharge as well as more bleeding complications. The risk:benefit ratio of VTE prophylaxis is 6 times worse in cancer patients due to bleeding. While bleeding occurs more frequently in cancer patients with platelet count <50x109/L, VTE occurs at a similar rate regardless of platelet count, meaning that cancer patients are at high risk of both clotting and bleeding. Recommendations for inpatient VTE prophylaxis for cancer patients require a targeted approach to identify a subset who would most benefit from VTE prophylaxis. Disclosures Flanders: Institute for Healthcare Improvement and the Society of Hospital Medicine: Consultancy; Wiley Publishing: Patents & Royalties; CDC Foundation: Research Funding; Blue Cross Blue Shield of Michigan: Research Funding; Michigan Hospital Association: Research Funding. Sood:Bayer: Research Funding.

Interim PET Evaluation By Deauville Criteria Is an Effective Risk Stratification Tool in PTCL

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 186-186 ◽  
Author(s):  
Neha Mehta-Shah ◽  
Kimiteru Ito ◽  
Kurt S Bantilan ◽  
Alison J Moskowitz ◽  
Craig S Sauter ◽  
...  
Keyword(s):  
At Risk ◽  
T Cell ◽  
Pet Imaging ◽  
Research Funding ◽  
Cell Lymphoma ◽  
Prognostic Index ◽  
Interim Pet ◽  
Patients At Risk ◽  
Deauville Criteria

Abstract Background: Peripheral T-cell lymphomas (PTCL) are a heterogeneous group of aggressive non-Hodgkin lymphomas. The most commonly used initial treatment is CHOP-based chemotherapy often followed by consolidation with an autologous transplant. 18-fluorodeoxyglucose positron emission tomography (PET) imaging is often used to evaluate response to therapy. While the international prognostic index (IPI) and Prognostic Index for T-cell Lymphoma (PIT) can help risk stratify patients, little data exists regarding the use of interim PET using the 5-point Deauville criteria in PTCL. Methods: We retrospectively identified patients with PTCL-not otherwise specified (PTCL-NOS),angioimmunoblastic T-cell lymphoma (AITL), andAlk-negative anaplastic large cell lymphoma (ALK- ALCL) in the Memorial Sloan Kettering Cancer Center (MSKCC) database who were initially treated with CHOP based therapy and had PET imaging between 2001 and 2015 and had at least 6 months follow up, or an event of progression or death. Baseline, interim and end of treatment PET scans werere-read for this study using the Deauville score. Data regarding disease characteristics, relapse and survival status were collected. Event free survival (EFS) and overall survival (OS) were estimated by Kaplan-Meier method, and compared by the log rank test. Results: 112 patients were identified with PTCL-NOS (n=40), AITL (n=49),ALK- ALCL (n=23) in the MSKCC database. Of these, 99 patients had interim PET images for review and 90 had PET images following cycle 6. The median estimated OS and EFS for the series was 93 months and 35 months respectively with a median follow up of 45 months. When evaluated by the Deauville criteria, patients with an interim PET with a score of 1-3 (n=83) had a median OS and EFS of 104 months and 64 months compared to those with a score of 4-5 (n=16) who had a median OS and EFS of 19 and 11 months (p<0.001). In this cohort, patients with baseline PIT score²1 (n=61) had a median EFS of 64 months compared to those with a score of >1 (n=51) who had a median EFS 24 months (p=0.019). Interim Deauville score more accurately identified patients at risk for poor outcome compared to baseline PIT score alone (p<0.001). (Figure 1A and 1B) In this cohort, patients with baseline IPI score²3 (n=90) had a median OS and EFS of 104 and 38 months compared to those with a score of >3 (n=22) who had a median OS and EFS of 51 and 13 months (p<0.05). Furthermore, interim Deauville further risk stratified patients compared to baseline IPI (p<0.001). Conclusion: Interim PET when evaluated by the 5-point Deauville criteria carries prognostic value in PTCL. In this cohort, interim PET more accurately identified patients at risk of poor outcome compared to baseline IPI and PIT. Disclosures Moskowitz: BMS: Consultancy; Seattle Genetics: Consultancy, Research Funding. Horwitz:Seattle Genetics: Consultancy, Research Funding; Huya: Consultancy; ADCT Therapeutics: Research Funding; Bristol-Myers Squibb: Consultancy; Infinity: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Kyowa Hakka Kirin: Consultancy, Research Funding; Celgene: Consultancy; Spectrum: Consultancy, Research Funding.

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