Impact of Hematology Electronic Consultations on Utilization of Referrals and Patient Outcomes in an Integrated Health Care System

INTRODUCTION Electronic consultations (e-consults) may be a valuable tool in the current era of increased demand for hematologists. Despite the increasing use of e-consults in hematology, their optimal utilization and impact on patient outcomes and workload are largely unknown. METHODS In this retrospective cohort study, we studied the hematology consult experience at Veterans Affairs Connecticut from 2006 to 2018. We included 7,664 hematology consults (3,240 e-consults and 4,424 face-to-face [FTF] consults) requested by 1,089 unique clinicians. RESULTS We found that e-consults were rapidly adopted and used equally among physicians of different degrees of experience. The number of FTF consults did not decrease after the introduction of e-consult services. E-consults were preferentially used for milder laboratory abnormalities that had been less likely to result in a consult before their availability. Referring clinicians used e-consults preferentially for periprocedural management, anemia, leukopenia, and anticoagulation questions. Eighty-three percent of e-consults were resolved without needing an FTF visit in the year after the consult. Consults for pancytopenia, gammopathy, leukocytosis, and for patients with known malignancy were less likely to be resolved by e-consult. Among patients who were diagnosed with a new hematologic malignancy after their consult, having an e-consult before an FTF visit did not adversely affect survival. CONCLUSION In summary, e-consults safely expanded delivery of hematology services in our health care system but increased total consult volume. We report novel data on what types of consults may be best suited to the electronic modality, the impact of e-consults on workload, and their optimal use and implementation.

Perioperative consultative hematology: can you clear my patient for a procedure?

Periprocedural management of antithrombotics is a common but challenging clinical scenario that renders patients vulnerable to potential adverse events such as bleeding and thrombosis. Over the past decade, periprocedural antithrombotic approaches have changed considerably with the advent of direct oral anticoagulants (DOACs), as well as a paradigm shift away from bridging in many warfarin patients. Successfully navigating this high-risk period relies on a number of individualized patient assessments conducted within a framework of standardized, systematic approaches. It also requires a thorough understanding of antithrombotic pharmacokinetics, multidisciplinary coordination of care, and comprehensive patient education and empowerment. In this article, we provide clinicians with a practical, stepwise approach to periprocedural management of antithrombotic agents through case-based examples of relevant clinical scenarios.

Rebalanced hemostasis in liver disease: a misunderstood coagulopathy

The combination of frequently abnormal hemostatic markers and catastrophic bleeding as seen with variceal hemorrhage has contributed to the longstanding misperception that chronic liver disease (CLD) constitutes a bleeding diathesis. Laboratory studies of hemostasis in liver disease consistently challenge this with global coagulation assays incorporating activation of the protein C pathway demonstrating rebalanced hemostasis. It is now recognized that bleeding in CLD is predominantly secondary to portal hypertension (rather than a coagulopathy) and additionally that these patients are at increased risk of venous thrombosis, particularly in the portal venous system. This narrative review describes the current understanding of hemostasis in liver disease, as well as the periprocedural management of hemostasis and anticoagulation for management of venous thromboembolism in patients with CLD.

Management of Edoxaban Therapy in Patients Undergoing Major Surgery: A Sub-Analysis of the Prospective, Observational, Multinational Emit-AF/VTE Study

Introduction Periprocedural management of patients on direct oral anticoagulants (DOAC) undergoing major surgical procedures is mainly based on pharmacokinetic considerations, clinical experience as described in the Dresden Registry (Beyer-Westendorf et al. Eur Heart J. 2014;35: 1888-186.) and the PAUSE study (Douketis JD et al. JAMA Intern Med. 2019;2019;179:1469-78), and on expert opinion. The objective of this study was to describe the background characteristics, periprocedural management, and outcomes of patients taking edoxaban who underwent major surgery in routine clinical practice. Methods Patients evaluated were participants in the EMIT AF/ VTE study (Colonna P et al. Clin Cardiol. 2020 Jul;43:769-80) which analyzed data on the risks of bleeding and thromboembolic events in 1,479 patients taking edoxaban who underwent unselected diagnostic or therapeutic procedures in routine clinical practice. Patients undergoing major surgery were compared with those who underwent non-major surgery. Physicians directed management of edoxaban, especially for dosing interruption, in accordance with locally approved labelling and guidelines such as those of the European Heart Rhythm Association (EHRA). Patients were evaluated from five days before until 29 days after the procedure. The primary outcome was the incidence of major bleeding as defined by the International Society on Thrombosis and Haemostasis; secondary outcomes included the incidence of clinically relevant non-major bleeding (CRNM), acute coronary syndrome (ACS), acute thromboembolic events (ATE) as well as the perioperative interruption times and use of bridging agents. Results Of the 1,478 patients, 128 (8.7%) underwent major-surgery as defined in the Dresden registry and PAUSE study. Background characteristics are summarized in Table 1 and medical history in Table 2. Surgeries by medical specialties are listed in Table 3. Major surgery vs non-major surgery patients had more often atrial fibrillation and dyslipidemia and exhibited higher CHA 2DS 2-VASc and HAS-BLED scores. Peri-procedurally, heparin was used significantly more often in patients with major surgery vs non-major surgery (42/128 (32%) vs 142/1351 (10.5%), p<0.001). Outcomes are summarized in Table 4. There were no significant differences in severe adverse outcomes between the two groups. Pre-procedural and post procedural interruption of edoxaban was longer in the major surgery group. See Table 5. Discussion The edoxaban interruption pattern was statistically different between major and non-major surgery patients. The rates of peri-procedural bleeding and acute thromboembolic events were low when patients were managed according to a clinical experience-driven management protocol. This is in line with the results in prior publications evaluating other direct oral anticoagulants. These results are important to optimize clinical management of patients undergoing elective procedures and will help to support guidelines for the peri-procedural management of edoxaban. Figure 1 Figure 1. Disclosures von Heymann: Daiichi Sankyo: Honoraria, Research Funding; Bayer AG: Honoraria, Research Funding; Bristol Myers Squibb: Honoraria, Research Funding; CSL Behring: Honoraria, Research Funding; NovoNordisk Pharma: Honoraria, Research Funding; Mitsubishi Pharma: Honoraria, Research Funding; Biotest GmbH: Honoraria, Research Funding; Grunenthal GmbH: Honoraria, Research Funding; HICC GbR: Honoraria, Research Funding; German Society of Anaesthesiology and Intensive Care Medicine: Honoraria, Other: Other Mandated to write several guidelines and part of writing groups of guidelines, Research Funding; European Society of Cardiothoracic Anesthesiologists: Other: Other Mandated to write several guidelines and part of writing groups of guidelines; Deutsche Gesellschaft für Gynäkologie und Geburtshilfe: Honoraria, Research Funding; European Society of Anaesthesiology and Intensive Care (ESAIC): Other: Mandated to write several guidelines and part of writing groups of guidelines. Unverdorben: Daiichi Sankyo: Current Employment. Colonna: Boehringer: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; European Society of Cardiology: Other: Mandated to write ESC-Guidelines on AF; Daiichi Sankyo: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Bristol Myers Squibb: Honoraria, Research Funding. Ortiz: Bayer: Consultancy; Daiichi Sankyo: Consultancy; Boehringer: Consultancy; Pfizer: Consultancy; Bristol Myers Squibb: Consultancy. Saxena: Recor Medical Inc: Consultancy, Research Funding, Speakers Bureau; Daiichi Sankyo: Consultancy, Research Funding, Speakers Bureau; The Medicines Company: Consultancy, Research Funding, Speakers Bureau; Ablative Solutions Inc: Consultancy, Research Funding, Speakers Bureau; Vascular Dynamics Inc: Consultancy, Honoraria, Speakers Bureau; Esperion Inc: Consultancy, Honoraria, Speakers Bureau; Vifor Pharma: Honoraria, Speakers Bureau. Vanassche: Bayer: Consultancy, Speakers Bureau; Boehringer Ingelheim,: Consultancy, Speakers Bureau; Pfizer/BMS: Consultancy, Speakers Bureau; Daiichi Sankyo: Consultancy, Speakers Bureau. Weitz: Daiichi Sankyo: Consultancy, Speakers Bureau. Wilkins: Daiichi Sankyo: Honoraria. Chen: Daiichi Sankyo: Current Employment.

Periprocedural Management of Electroconvulsive Therapy in Pregnancy during COVID-19 Outbreak: The First Case Report in Thailand

Objective: To described the periprocedural electroconvulsive therapy (ECT) management of a patient in the 3rd trimester of pregnancy, the ECT complications, and their treatment. Materials and Methods: A retrospective chart review was conducted of a 26-year-old parturient with bipolar I disorder with psychotic features during the coronavirus disease 2019 (COVID-19) outbreak. Case Report: The patient was admitted and scheduled for ECT. Fifteen ECT sessions (eight on her first admission, and another seven on a second admission) were performed. General anesthesia with endotracheal intubation was conducted after sufficient preoxygenation. Complications were observed: prolonged seizure, decreased fetal heart rate, and hypersecretion. Nonetheless, good outcomes were achieved after treated with thiopental to terminate the seizure, intravenous crystalloid loading and left uterine displacement to stabilize the fetus, and suctioning and an antisialagogue for secretion clearance. Conclusion: In ECT during pregnancy, it can be challenging to apply electrical current, induce anesthesia and airway management to achieve safe patient care and ensure adequate seizure duration. Moreover, the ECT is conducted in a non-operating room setting where equipment may be deficient. A prerequisite is good periprocedural collaboration among members of the multidisciplinary team which include a psychiatrist, an anesthesiologist, and an obstetrics-gynecologist, as well as proper protective equipment to prevent the contamination to the environment. Keywords: Coronavirus disease 2019 (COVID-19); Electroconvulsive therapy (ECT); Multidisciplinary team; Periprocedural management; Pregnancy

Periprocedural management of patients on edoxaban undergoing pacemaker and cardiac monitoring device implantation - a sub-analysis of the EMIT-AF/VTE study

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background Periprocedural management of patients on direct oral anticoagulants undergoing insertion of permanent pacemaker (PPM) and cardiac monitoring devices is mainly based on pharmacokinetic considerations, clinical experience, and expert opinion. Purpose To describe the characteristics, periprocedural management, and events of edoxaban patients undergoing implantation of PPM/monitoring devices. Methods From the global EMIT-AF/VTE registry, which includes edoxaban patients undergoing any diagnostic or therapeutic procedures, those with PPM/cardiac monitoring device implantation were observed from five days prior to 30 days post procedure. Events documented included the incidence of International Society on Thrombosis and Haemostasis defined Major Bleeding, Clinically Relevant Non-Major Bleeding (CRNMB), acute thromboembolic events (ATE) and perioperative edoxaban interruption times. Results PPM or invasive cardiac monitoring devices were implanted in 136 patients. Conformance with European Heart Rhythm Association Guidance for the interruption of anticoagulation was variable: of the cardiac monitoring patients, 62.5% had interruption of treatment, whereas in PPM procedures 23.4% had no interruption. One case of CRNMB and two cases of minor bleeding were documented. All bleedings seem non procedure-related since they occurred > three days post procedure. There were no ATE. Conclusions Relevant complications for edoxaban treated patients undergoing PPM or invasive cardiac monitoring procedures were rare. This population of patients is apparently well managed in routine practice, but further investigation of risk factors is justified. TablePatient characteristics Parameter All subjectsN = 136 All pacemakerN = 128 Insertion first pacemakerN = 89 Change pacemakerN = 39 Monitoring deviceN = 8 Age, mean (SD)Male, n (%) 75.1 (10.1)85 (62.5) 75.0 (10.3)83 (64.8) 75.7 (9.9)57 (64.0) 73.5 (11.2)26 (66.7) 76.3 (4.3)2 (25.0) BMI, mean (SD) 27.1 (5.5) 27.2 (5.6) 27.2 (6.0) 27.3 (4.5) 25.2 (4.3) AF, n (%)‡ 135 (99.3) 127 (99.2) 89 (100.0) 38 (97.4) 8 (100.0) VTE, n (%)‡ 3 (2.2) 3 (2.3) 1 (1.1) 2 (5.1) 0 CrCL, mean (SD) 63.8 (26.4) 64.1 (26.7) 62.3 (26.2) 68.3 (27.9) 58.9 (21.8) CrCL, ≤50, n (%) 43 (31.6) 41 (32.0) 33 (37.1) 8 (20.5) 2 (25.0) HAS-BLED Score, mean (SD) 2.0 (1.2) 1.9 (1.2) 1.9 (1.0) 2.1 (1.6) 2.6 (0.5) CHA2DS2-VASc Score, mean (SD) 3.7 (1.6) 3.7 (1.6) 3.7 (1.5) 3.8 (1.9) 3.1 (0.6) Edoxaban 30 mg/day, n (%) 49 (36.0) 46 (35.9) 32 (36.0) 14 (35.9) 3 (37.5) Edoxaban 60 mg/day, n (%) 86 (63.2) 81 (63.3) 56 (62.9) 25 (64.1) 5 (62.5) AF, atrial fibrillation; BMI, body mass index; CrCL, creatinine clearance; VTE, venous thromboembolism. ‡Two patients had both AF and VTE.

Periprocedural anticoagulation management in edxoaban patients undergoing catheter-based cardiovascular procedures: analyses of the noninterventional global EMIT study

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background The optimal periprocedural management of direct oral anticoagulants (DOAC), including edoxaban, in patients undergoing catheter-based cardiovascular procedures is unknown, and mainly based on physician opinion and experience. Purpose To assess real-world management of edoxaban in patients undergoing cardiovascular procedures, and to report their clinical events. Methods Global EMIT-AF/VTE is a prospective study of periprocedural management in edoxaban-treated patients undergoing diagnostic and therapeutic procedures. We report the data from patients undergoing cardiovascular procedures. Timing and duration of edoxaban interruption were at the treating physician’s discretion. Outcomes were collected from 5 days before until 30 days post procedure. Primary outcome was the incidence of major bleeding (MB); secondary outcomes included incidence of clinically relevant non-major bleeding (CRNMB) and acute thromboembolic events (ATE). Results Data was collected from 301 and 311 procedures with arterial or venous access, respectively. Baseline characteristics are shown in Table 1. Edoxaban was not interrupted in 36.9% of arterial and 52.7% of venous procedures. Edoxaban was interrupted pre-procedure in 41% of arterial and 32.8% of venous procedures. The median periprocedural interruption was 2 days. The overall incidence of bleeding was very low. Any bleeding was reported in 8 patients undergoing arterial and 10 patients undergoing venous procedures (2.7% and 3.2%). MB or CRNMB occurred in 2 arterial and 3 venous procedures (0.7% and 1.0%) and ATE occurred in 5 arterial and 1 venous procedure (1.7% and 0.3%, Table 1). Conclusions In this study, the periprocedural risks of bleeding and thrombotic events were low. About a third of arterial access procedures and half of venous access procedures were performed without edoxaban interruption. Arterial(n = 301) Venous(n = 311) Baseline characteristics Age, year, mean (SD)Male, n (%)Weight (kg), mean (SD) 71.9 (8.5)211 (70.1%)80.8 (16.7) 64.6 (11.1)215 (69.1%)84.1 (17.4) CrCL (mL/min), mean (SD) CHA2DS2-VASc score, mean (SD)HAS-BLED score, mean (SD) 73.5 (29.8) 3.3 (1.5)2.0 (1.0) 88.9 (35.5) 2.2 (1.5)1.3 (1.0) Edoxaban 60 mg / 30 mg, % 73% / 26% 88% / 26% Coronary heart disease, n (%) Congestive heart failure, n (%) 101 (33.6%) 58 (19.3%) 51 (16.4%) 33 (10.6%) Interruption of edoxaban, n (%) No interruption Pre-procedure only Post-procedure only Pre- and post-procedure 111 (36.9%)125 (41.5%)12 (4.0%)53 (17.6%) 164 (52.7%)102 (32.8%)8 (2.6%)37 (11.9%) Clinical events, n (%) MB or CRNMBACSStroke/Transient ischemic attackCV mortalityAll-cause mortality 2 (0.7%)2 (0.7%)3 (1.0%)1 (0.3%)2 (0.7%) 3 (1.0%) 01 (0.3%)00