Anticoagulant therapy management of venous thromboembolism recurrence occurring during anticoagulant therapy: a descriptive study.

Limited evidence exists regarding management of recurrent venous thromboembolism (VTE) that occurs during anticoagulant therapy. We aimed to describe patient characteristics, drug therapy management, and outcomes of patients with VTE recurrence during anticoagulant therapy. We identified 30 relevant episodes of VTE recurrence. Mean age was 48.9 (15.9) years, 56.7% were male, and 93.3% were White. Common VTE risk factors included cancer (46.6%), recent surgery (33.3%), and prolonged immobility (30.0%). At the time of recurrent VTE, 40.0% were receiving enoxaparin, 30.0% warfarin, and 23.3% direct oral anticoagulants. Potential causes for VTE recurrence included indwelling venous catheters (40.0%), cancer (33.3%), subtherapeutic anticoagulation (26.7%), and nonadherence (23.3%). Recurrent VTE management strategies included switching anticoagulants (26.7%), increasing anticoagulant dose (20.0%), temporarily adding enoxaparin or unfractionated heparin to oral anticoagulation therapy (13.3%), or no change in anticoagulation therapy (43.3%). Only four adverse 90-day outcomes occurred among 17 patients who received anticoagulant therapy changes in response to VTE recurrence, whereas eight adverse outcomes occurred in the 13 patients who received no change in anticoagulation therapy in response to a recurrent VTE episode (P value 0.04). Regardless of the potential etiology of recurrent VTE during anticoagulant therapy; switching anticoagulants, temporarily adding injectable anticoagulants, or increasing anticoagulant intensity appears preferable to continuing current anticoagulant therapy unchanged.

Impact of Hospitalist Team Structure on Patient-Reported Satisfaction with Physician Performance.

BACKGROUND: Patient experience is valuable because it reflects how patients perceive the care they receive within the healthcare system and is associated with clinical outcomes. Also, as part of the Hospital Value-Based Purchasing (HVBP) program, the Center for Medicare and Medicaid Services (CMS) rewards hospitals with financial incentives for patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. It is unclear how the addition of residents and advanced practice clinicians (APCs) to hospitalist-led inpatient teams affects patient satisfaction as measured by the HCAHPS and Press Ganey survey. OBJECTIVE: To compare patient satisfaction with hospitalists on resident, APC, and solo hospitalist teams measured by HCAHPS and Press Ganey physician performance domain survey results. DESIGN: Retrospective observational cohort study. PARTICIPANTS: All patients discharged from the Internal Medicine inpatient service between July 1, 2015, and July 1, 2018, who met HCAHPS survey eligibility criteria and completed a patient experience survey. MAIN MEASURES: HCAHPS and Press Ganey physician performance domain survey results. KEY RESULTS: No differences were observed in the selection of "top box" scores on the HCAHPS physician performance domain between resident, APC, and solo hospitalist teams. Adjusted Press Ganey physician performance domain survey results demonstrated significant differences between solo hospitalist and resident teams, with solo hospitalists having higher scores in three areas: time physician spent with you (4.58 vs. 4.38, p = 0.050); physician kept you informed (4.63 vs. 4.43, p = 0.047); and physician skill (4.80 vs. 4.63, p = 0.027). Solo hospitalists were perceived to have higher physician skill in comparison with hospitalist-APC teams (4.80 vs. 4.69, p = 0.042). CONCLUSION: While Press Ganey survey results suggest that patients have greater satisfaction with physicians on solo hospitalist teams, these differences were not observed on the HCAHPS physician performance survey domain, suggesting physician team structure does not impact HVBP incentive payments by CMS.

Assessing the accuracy of ICD-10 codes for identifying acute thromboembolic events among patients receiving anticoagulation therapy.

International classification of disease (ICD) codes can improve the efficiency of epidemiological research provided the codes accurately identify outcomes of interest. The purpose of this retrospective cross-sectional study is to evaluate the accuracy of ICD-10 codes for identifying thromboembolic events occurring during anticoagulation therapy. Medical charts of patients hospitalized for any reason while receiving anticoagulant therapy between September 1, 2017 and December 31, 2017 were reviewed by two reviewers blinded to ICD-10 code status. Following identification of confirmed acute thromboembolic events, ICD-10 codes were unblinded and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) along with 95% confidence intervals (CI) were calculated for coding in any diagnosis position ("principal" or "other"). There were 661 hospitalizations identified among 487 anticoagulated patients. There were 27 thromboembolic events identified during chart review. Stroke and venous thromboembolism were the most common thromboembolic event types. Overall thromboembolic ICD-10 coding sensitivity was 100.0% (95% CI 87.2-100.0); specificity was 79.3% (75.9-82.4). PPV was 17.1% (11.6-23.9%), and NPV was 100% (99.3-100.0). ICD-10 codes can reliably be used for ruling out hospitalizations for thromboembolic events in patients receiving anticoagulation therapy but should not be used for identifying thromboembolic complications without confirmatory chart review.

Angiotensin receptor signaling and prostate tumor growth in mice.

OBJECTIVE: The renin-angiotensin system, through its type 1 and type 2 angiotensin receptors (AT1R and AT2R, respectively) may have a role in prostate cancer. The objective of this pilot study was to explore that potential role by determining whether the AT1R blocker, losartan, would reduce the growth of LAPC-4 prostate cancer xenografts in nude mice. We also evaluated the tumor growth effects of using angiotensin II to activate both AT1R and AT2R simultaneously. Our data showed that losartan decreased tumor volumes by 56% versus control. This decrease reached statistical significance at day 54 (p = 0.0014). By day 54, Ki67 was also reduced in the losartan group, though not significantly so (p = 0.077). Losartan had no significant effect on AT1R or AT2R expression. Despite significant increases in both AT1R and AT2R at day 29 (p = 0.043 and 0.038, respectively), the administration of angiotensin II did not result in any significant differences in tumor volumes or ki67 at any time point. These data suggest that selective activation and induction of AT2R coupled with blockade of AT1R may slow prostate cancer growth. Future larger studies are needed to confirm these results.

Twenty years after ACEIs and ARBs: emerging treatment strategies for diabetic nephropathy.

Diabetic nephropathy (DN) is a serious complication of both type 1 and type 2 diabetes mellitus. The disease is now the most common cause of end-stage kidney disease (ESKD) in developed countries, and both the incidence and prevalence of diabetes mellitus is increasing worldwide. Current treatments are directed at controlling hyperglycemia and hypertension, as well as blockade of the renin angiotensin system with angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers. Despite these therapies, DN progresses to ESKD in many patients. As a result, much interest is focused on developing new therapies. It has been over two decades since ACEIs were shown to have beneficial effects in DN independent of their blood pressure-lowering actions. Since that time, our understanding of disease mechanisms in DN has evolved. In this review, we summarize major cell signaling pathways implicated in the pathogenesis of diabetic kidney disease, as well as emerging treatment strategies. The goal is to identify promising targets that might be translated into therapies for the treatment of patients with diabetic kidney disease.

Clinical Outcomes of Orthopedic Surgery Co-Management by Internal Medicine Advanced Practice Clinicians: A Cohort Study.

BACKGROUND: Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. Our objecyive was to compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. METHODS: This is a retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014 and January 1, 2022. Outcomes assessed were length of stay, intensive care unit (ICU) transfer, return to operating room, in-hospital and 30-day mortality, 30-day readmission, and total direct cost, excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and health care cost between usual care and advanced practice clinician comanagement. RESULTS: Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (rate ratio = 0.95, P = .009), decreased odds of returning to the operating room (odds ratio [OR] 0.51, P = .002), and a significant reduction in 30-day mortality (OR 0.32, P = .037) compared with usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR 1.54, P = .009), without significant differences in 30-day readmission or in-hospital mortality. CONCLUSIONS: We observed reductions in length of stay, health care costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared with usual orthopedic care. Our findings suggest that advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.

Inpatient opioid withdrawal: a qualitative study of the patient perspective.

Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.

Comparison of internal medicine applicant and resident characteristics with performance on ACGME milestones.

Internal medicine (IM) residency programs select applicants based on several metrics. Factors predicting success during residency are unclear across studies. To identify whether specific applicant or resident factors are associated with IM resident performance using ACGME milestones. We tested for associations between applicant factors available prior to the start of IM residency and resident factors measured during IM residency training, and resident performance on ACGME milestones across three consecutive years of IM training between 2015-2020. Univariable and multivariable linear regression modeling was used to test associations. Eighty-nine categorical IM residents that completed 3 consecutive years of training were included. Median age was 28 years (IQR 27-29) and 59.6% were male. Mean ACGME milestone scores increased with each post-graduate year (PGY) from 3.36 (SD 0.19) for PGY-1, to 3.80 (SD 0.15) for PGY-2, to 4.14 (SD 0.15) for PGY-3. Univariable modeling suggested referral to the clinical competency committee (CCC) for professionalism concerns was negatively associated with resident performance during each PGY. No applicant or resident factors included in the final multivariable regression models (age at starting residency, USMLE Step scores, interview score, rank list position, ITE scores) were associated with ACGME milestone scores for PGY-1 and PGY-2. Referral to the CCC for professionalism was negatively associated with resident performance during PGY-3. Residency selection factors did not predict resident milestone evaluation scores. Referral to the CCC was associated with significantly worse resident evaluation scores, suggesting professionalism may correlate with clinical performance.

Insulin for Hospitalized Patients With Well-Controlled Type 2 Diabetes Mellitus: A Quality Improvement Initiative.

ABSTRACT: Inpatient management of diabetes mellitus (DM) often involves substituting oral medications with insulin which can result in unnecessary insulin use. Attempting to address unnecessary insulin use, a quality improvement initiative implemented a newly developed evidence-based care pathway for inpatient diabetes management focused on patients with recent hemoglobin A1c values < 8% and no prescription of outpatient insulin. This retrospective observational preintervention and postintervention and interrupted time series analysis evaluates this intervention. Over a 21-month time period, there was a significant decrease in mean units of insulin administered per day of hospitalization from 2.7 (2.2-3.3) in the preintervention group to 1.7 (1.2-2.3) in the postintervention group ( p = .017). During the initial 72 hours after admission, a significant downward trend in mean glucose values and mean insulin units per day was seen after the intervention. There was no significant change in hypoglycemic or hyperglycemic events between the two groups. The proportion of patients who received zero units of insulin during their admission increased from 27.7% to 52.5% after the intervention ( p < .001). An evidence-based pathway for inpatient management of DM was associated with decreased insulin use without significant changes in hypoglycemic or hyperglycemic events.

A multifaceted quality improvement intervention to improve management of alcohol withdrawal on a general medicine ward: impact on benzodiazepine use.

OBJECTIVE: To measure the effects of a quality improvement intervention on length of stay and benzodiazepine use among patients admitted for alcohol use disorder. METHODS: This retrospective cohort study was performed at the Salt Lake City Veterans Affairs Medical Center. Patients 18 years and older admitted to a general medical ward with a diagnosis of alcohol related disorders who were treated for alcohol withdrawal were included. The baseline cohort included patients admitted over 12 months. The post-intervention cohort included patients admitted over 12 months. Primary outcomes were total benzodiazepine dose and length of stay. Secondary outcomes included episodes of delirium tremens and seizures. RESULTS: Total benzodiazepine dose decreased significantly over the intervention period. Length of stay also decreased. No episodes of delirium tremens or seizures were observed. CONCLUSIONS: A quality improvement intervention directed at general medicine inpatients admitted for alcohol withdrawal was associated with reductions in total benzodiazepine administration and length of stay.

Reimagining Learning Spaces of the Future: An Interprofessional, Virtual Workshop Utilizing Rapid Idea Generation and Lean Startup Methodologies.

INTRODUCTION: The needs and expectations of health professional educators and learners are evolving. Therefore, physical and virtual learning environments will look and function differently in the future. Understanding desirable, feasible options for educators and learners, including online, in-person, hybrid, and extended realities, is critical. We designed and facilitated a faculty development workshop that adapted Lean Startup methodologies and role-modeled effective virtual teaching skills to engage stakeholders in generating ideas to inform future development of learning spaces within one national academic medical center. METHODS: We facilitated the 3-hour workshop with an interprofessional group of health professional educators, learners, and administrative staff. The workshop included asynchronous prework and synchronous microlectures, small-group activities, and large-group report-outs. We employed Lean Startup methodologies to promote divergent thinking. Each small group had a dedicated convener and scribe. A designated chat moderator, social media facilitator, and several audiovisual staff provided support during the workshop. RESULTS: More than 4,000 ideas were generated by the 350 participants. Participants reported that prework, microlectures, and small-group activities were successful in preparing them to engage in rapid idea generation and propose potential solutions for future learning spaces within health professions education. DISCUSSION: The workshop, which utilized a rapid idea generation and Lean Startup methodologies format, was successful in producing an abundance of original ideas and potential solutions for future learning spaces within health professions education. As reported through postsession evaluation, participants valued the opportunity to contribute ideas and co-create potential solutions to guide future planning and feasibility studies.

Effects of Short-Term Air Pollution Exposure on Venous Thromboembolism: A Case-Crossover Study.

Rationale: Exposure to outdoor air pollution is associated with increased cardiovascular disease, respiratory illness, and mortality. The effect of air pollution on venous thromboembolism (VTE) is less certain. Objectives: To test for associations between short-term exposure to air pollution and VTE. Methods: This is a retrospective case-crossover study of adult patients with an objectively confirmed VTE event. Exposure to the mean and maximum particulate matter ⩽2.5 µm in aerodynamic diameter (PM2.5) and ozone were estimated with inverse distance squared weighting from multiple stationary air quality monitors. Conditional logistic regression with a 7-day individual lag model estimated the odds ratio (OR) of VTE occurrence during the case period relative to the referent period. Prespecified subgroup analysis was performed to further test associations in higher risk patients. Results: A total of 2,803 VTE events met inclusion criteria for analysis. Deep vein thrombosis was identified in 1,966 (70.1%) and pulmonary embolism in 915 (32.6%) subjects. Median age was 57 years. Small negative associations were observed for the maximum PM2.5 exposure at 1 day (OR, 0.992; 95% confidence interval [CI], 0.986-0.997) and the mean PM2.5 exposure at 1 day (OR, 0.982; 95% CI, 0.97-0.994), 5 days (OR, 0.987; 95% CI, 0.975-0.999), 6 days (OR, 0.984; 95% CI, 0.972-0.996), and 7 days (OR, 0.982; 95% CI, 0.971-0.994) before VTE diagnosis. Similar negative associations were observed for the 8-hour mean (OR, 0.989; 95% CI, 0.981-0.997) and 8-hour maximum (OR, 0.992; 95% CI, 0.985-0.999) ozone exposure 4 days before VTE diagnosis. Positive relationships (ORs of ∼1.02) between the 8-hour mean and maximum ozone exposures 6-7 days preceding VTE diagnosis were observed in a recently hospitalized subgroup. Conclusions: Short-term exposure to PM2.5 and ozone does not appear to be associated with an overall increased risk of VTE. Further well-designed studies are needed to test whether previously reported associations between VTE and air pollution exist.

Outcomes of isolated distal thrombosis managed with serial compression ultrasonography.

BACKGROUND: Isolated distal deep vein thrombosis (IDDVT) is a common subtype of deep vein thrombosis (DVT). Consensus guidelines provide conflicting recommendations for IDDVT management; some recommend anticoagulant treatment, while others suggest serial compression ultrasonography (CUS) monitoring for patients not at "high risk" of proximal extension. The purpose of this study was to describe outcomes of serial CUS-monitored IDDVT and identify risk factors for proximal thrombus extension or anticoagulant treatment initiation. METHODS: A retrospective descriptive study was conducted using electronic data from University of Utah Health. Adult subjects with objectively confirmed, serial CUS-monitored IDDVT were included. Subjects were followed for 30 days for occurrence of a composite outcome of proximal thrombus extension or anticoagulant treatment initiation. Descriptive statistics were used to summarize characteristics of the study population. Characteristics were compared across outcome groups using inferential statistics. RESULTS: A total of 182 subjects were included, with 53 subjects (29.1%) experiencing the composite outcome. Of these, 12 (22.6%) experienced proximal thrombus extension and 41 (77.4%) initiated anticoagulant treatment. A prior history of venous thromboembolism (VTE) was significantly higher in those who experienced the composite outcome than in those who did not. CONCLUSIONS: Our results suggest that 70% of patients with serial CUS-monitored IDDVT did not experience thrombus extension or require anticoagulant treatment within 30 days of diagnosis, regardless of risk factors for proximal extension. Serial CUS monitoring may be a useful management strategy for IDDVT. A history of VTE may identify patients more likely to experience proximal thrombus extension or require anticoagulation.

A risk-stratified approach to venous thromboembolism prophylaxis with aspirin or warfarin following total hip and knee arthroplasty: A cohort study.

INTRODUCTION: Venous thromboembolism (VTE) and bleeding events following total knee and hip arthroplasty (TKA/THA) are associated with significant morbidity. Clinical guidelines recommend administration of pharmacologic VTE prophylaxis post-operatively, although controversy exists regarding optimal prophylactic strategies. METHODS: We performed a retrospective cohort study in patients who underwent elective TKA/TKA in an academic medical center. Patients were stratified by surgery type (TKA/THA) and VTE risk determined by a novel risk stratification protocol and compared pre- and post-protocol implementation. Patients received warfarin pre-protocol and either aspirin or warfarin post-protocol for VTE prophylaxis. Natural language processing identified VTE events and ICD codes were used to identify bleeding events, with all events validated manually. RESULTS: A total of 1379 surgeries were included for analysis, 839 TKAs and 540 THAs. Post-protocol implementation, 445 (94.1%) patients following TKA and 294 (97.4%) patients following THA received aspirin for VTE prophylaxis. A significant reduction in bleeding events (hazard ratio [HR] = 0.19, p = 0.048) was observed in low-risk THA patients treated with aspirin (post-protocol) compared patients treated with warfarin (pre-protocol). Bleeding events did not differ significantly between low-risk TKA patients treated with aspirin or warfarin. No significant differences in VTE events were observed following the protocol implementation. CONCLUSIONS: The use of a novel risk stratification system to guide VTE prophylaxis selection between aspirin or warfarin following TKA and THA appears safe and effective. Among low-risk patients, aspirin use was associated with fewer bleeding events following THA, without an observed increase in VTE events.

A comparison of natural language processing to ICD-10 codes for identification and characterization of pulmonary embolism.

INTRODUCTION: The 10th revision of the International Classification of Diseases (ICD-10) codes is frequently used to identify pulmonary embolism (PE) events, although the validity of ICD-10 has been questioned. Natural language processing (NLP) is a novel tool that may be useful for pulmonary embolism identification. METHODS: We performed a retrospective comparative accuracy study of 1000 randomly selected healthcare encounters with a CT pulmonary angiogram ordered between January 1, 2019 and January 1, 2020 at a single academic medical center. Two independent observers reviewed each radiology report and abstracted key findings related to PE presence/absence, chronicity, and anatomic location. NLP interpretations of radiology reports and ICD-10 codes were queried electronically and compared to the reference standard, manual chart review. RESULTS: A total of 970 encounters were included for analysis. The prevalence of PE was 13% by manual review. For PE identification, sensitivity was similar between NLP (96.0%) and ICD-10 (92.9%; p = 0.405), and specificity was significantly higher with NLP (97.7%) compared to ICD-10 (91.0%; p < 0.001). NLP demonstrated higher sensitivity (70.0% vs 16.5%, p < 0.001) and specificity (99.9% vs 99.4%, p = 0.014) for saddle/main PE recognition, and significantly higher sensitivity (86.7% vs 8.3%, p < 0.001) and specificity (99.8% vs 96.5%, p < 0.001) for subsegmental PE compared to ICD-10. CONCLUSIONS: NLP is highly sensitive for PE identification and more specific than ICD-10 coding. NLP outperformed ICD-10 coding for recognition of subsegmental, saddle, and chronic PE. Our results suggest NLP is an efficient and more reliable method than ICD-10 for PE identification and characterization.

Natural language processing for the surveillance of postoperative venous thromboembolism.

BACKGROUND: The objective of this study was to develop a portal natural language processing approach to aid in the identification of postoperative venous thromboembolism events from free-text clinical notes. METHODS: We abstracted clinical notes from 25,494 operative events from 2 independent health care systems. A venous thromboembolism detected as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used as the reference standard. A natural language processing engine, easy clinical information extractor-pulmonary embolism/deep vein thrombosis (EasyCIE-PEDVT), was trained to detect pulmonary embolism and deep vein thrombosis from clinical notes. International Classification of Diseases (ICD) discharge diagnosis codes for venous thromboembolism were used as baseline comparators. The classification performance of EasyCIE-PEDVT was compared with International Classification of Diseases codes using sensitivity, specificity, area under the receiver operating characteristic curve, using an internal and external validation cohort. RESULTS: To detect pulmonary embolism, EasyCIE-PEDVT had a sensitivity of 0.714 and 0.815 in internal and external validation, respectively. To detect deep vein thrombosis, EasyCIE-PEDVT had a sensitivity of 0.846 and 0.849 in internal and external validation, respectively. EasyCIE-PEDVT had significantly higher discrimination for deep vein thrombosis compared with International Classification of Diseases codes in internal validation (area under the receiver operating characteristic curve: 0.920 vs 0.761; P < .001) and external validation (area under the receiver operating characteristic curve: 0.921 vs 0.794; P < .001). There was no significant difference in the discrimination for pulmonary embolism between EasyCIE-PEDVT and ICD codes. CONCLUSION: Accurate surveillance of postoperative venous thromboembolism may be achieved using natural language processing on clinical notes in 2 independent health care systems. These findings suggest natural language processing may augment manual chart abstraction for large registries such as NSQIP.

Side-Effects of COVID-19 on Patient Care: An INR Story.

BACKGROUND: Numerous studies have documented reduced access to patient care due to the COVID-19 pandemic, including access to diagnostic or screening tests, prescription medications, and treatment for an ongoing condition. In the context of clinical management for venous thromboembolism, this could result in suboptimal therapy with warfarin. We aimed to determine the impact of the pandemic on utilization of International Normalized Ratio (INR) testing and the percentage of high and low results. METHODS: INR data from 11 institutions were extracted to compare testing volume and the percentage of INR results ≥3.5 and ≤1.5 between a pre-pandemic period (January-June 2019, period 1) and a portion of the COVID-19 pandemic period (January-June 2020, period 2). The analysis was performed for inpatient and outpatient cohorts. RESULTS: Testing volumes showed relatively little change in January and February, followed by a significant decrease in March, April, and May, and then returned to baseline in June. Outpatient testing showed a larger percentage decrease in testing volume compared to inpatient testing. At 10 of the 11 study sites, we observed an increase in the percentage of abnormal high INR results as test volumes decreased, primarily among outpatients. CONCLUSION: The COVID-19 pandemic impacted INR testing among outpatients which may be attributable to several factors. Increased supratherapeutic INR results during the pandemic period when there was reduced laboratory utilization and access to care is concerning because of the risk of adverse bleeding events in this group of patients. This could be mitigated in the future by offering drive-through testing and/or widespread implementation of home INR monitoring.

Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis.

CONTEXT: In patients with suspected lower extremity deep vein thrombosis (DVT), compression ultrasound (CUS) is typically the initial test to confirm or exclude DVT. Patients with an initial negative CUS result often require repeat CUS after 5 to 7 days. Whole-leg CUS may exclude proximal and distal DVT in a single evaluation. OBJECTIVE: To determine the risk of venous thromboembolism after withholding anticoagulation in patients with suspected lower extremity DVT following a single negative whole-leg CUS result. DATA SOURCES: MEDLINE, EMBASE, CINAHL, LILACS, Cochrane, and Health Technology Assessments databases were searched for articles published from January 1970 through November 2009. Supplemental searches were performed of Internet resources, reference lists, and by contacting content experts. STUDY SELECTION: Included studies were randomized controlled trials and prospective cohort studies of patients with suspected DVT and a negative whole-leg CUS result who did not receive anticoagulant therapy, and were followed up at least 90 days for venous thromboembolism events. DATA EXTRACTION: Two authors independently reviewed and extracted data regarding a single positive or negative whole-leg CUS result, occurrence of venous thromboembolism during follow-up, and study quality. RESULTS: Seven studies were included totaling 4731 patients with negative whole-leg CUS examinations who did not receive anticoagulation. Of these, up to 647 patients (13.7%) had active cancer and up to 725 patients (15.3%) recently underwent a major surgery. Most participants were identified from an ambulatory setting. Venous thromboembolism or suspected venous thromboembolism-related death occurred in 34 patients (0.7%), including 11 patients with distal DVT (32.4%); 7 patients with proximal DVT (20.6%); 7 patients with nonfatal pulmonary emboli (20.6%); and 9 patients (26.5%) who died, possibly related to venous thromboembolism. Using a random-effects model with inverse variance weighting, the combined venous thromboembolism event rate at 3 months was 0.57% (95% confidence interval, 0.25%-0.89%). CONCLUSION: Withholding anticoagulation following a single negative whole-leg CUS result was associated with a low risk of venous thromboembolism during 3-month follow-up.