ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease.

Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Treatment of patients hospitalized for COVID-19 with remdesivir is associated with lower likelihood of 30-day readmission: a retrospective observational study.

Aim: This observational study investigated the association between remdesivir treatment during hospitalization for COVID-19 and 30-day COVID-19-related and all-cause readmission across different variants time periods. Patients & methods: Hospitalization records for adult patients discharged from a COVID-19 hospitalization between 1 May 2020 to 30 April 2022 were extracted from the US PINC AI Healthcare Database. Likelihood of 30-day readmission was compared among remdesivir-treated and nonremdesivir-treated patients using multivariable logistic regression models adjusted for age, corticosteroid treatment, Charlson comorbidity index and intensive care unit stay during the COVID-19 hospitalization. Analyses were stratified by maximum supplemental oxygen requirement and variant time period (pre-Delta, Delta and Omicron). Results: Of the 440,601 patients discharged alive after a COVID-19 hospitalization, 248,785 (56.5%) patients received remdesivir. Overall, remdesivir patients had a 30-day COVID-19-related readmission rate of 3.0% and all-cause readmission rate of 6.3% compared with 5.4% and 9.1%, respectively, for patients who did not receive remdesivir during their COVID-19 hospitalization. After adjusting for demographics and clinical characteristics, remdesivir treatment was associated with significantly lower odds of 30-day COVID-19-related readmission (odds ratio 0.60 [95% confidence interval: 0.58-0.62]), and all-cause readmission (0.73 [0.72-0.75]). Significantly lower odds of 30-day readmission in remdesivir-treated patients was observed across all variant time periods. Conclusion: Treating patients hospitalized for COVID-19 with remdesivir is associated with a statistically significant reduction in 30-day COVID-19-related and all-cause readmission across variant time periods. These findings indicate that the clinical benefit of remdesivir may extend beyond the COVID-19 hospitalization.

Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

A Least Absolute Shrinkage and Selection Operator-Derived Predictive Model for Postoperative Respiratory Failure in a Heterogeneous Adult Elective Surgery Patient Population.

BACKGROUND: Postoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients. RESEARCH QUESTION: Can a predictive model be developed to accurately identify patients at high risk of PRF? STUDY DESIGN AND METHODS: In this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores. RESULTS: Two hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m2; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO2, end title CO2, heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203). INTERPRETATION: This single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

Managing hospitalized patients with a COPD exacerbation: the role of hospitalists and the multidisciplinary team.

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with high rates of hospitalizations, costs, and morbidity. Therefore, hospitalists and the multidisciplinary team (hospital team) need to take a proactive approach to ensure patients are effectively managed from hospital admission to postdischarge. Comprehensive screening and diagnostic testing of patients at admission will enable an accurate diagnosis of COPD exacerbations, and severity, as well as other factors that may impact the length of hospital stay. Depending on the exacerbation severity and cause, pharmacotherapies may include short-acting bronchodilators, systemic corticosteroids, and antibiotics. Oxygen and/or ventilatory support may benefit patients with demonstrable hypoxemia. In preparation for discharge, the hospital team should ensure that patients receive the appropriate maintenance therapy, are counseled on their medications including inhalation devices, and proactively discuss smoking cessation and vaccinations. For follow-up, effective communication can be achieved by transferring discharge summaries to the primary care physician via an inpatient case manager. An inpatient case manager can support both the hospitalist and the patient in scheduling follow-up appointments, sending patient reminders, and confirming that a first outpatient visit has occurred. A PubMed search (prior to 26 January 2021) was conducted using terms such as: COPD, exacerbation, hospitalization. This narrative review focuses on the challenges the hospital team encounters in achieving optimal outcomes in the management of patients with COPD exacerbations. Additionally, we propose a novel simplified algorithm that may help the hospital team to be more proactive in the diagnosis and management of patients with COPD exacerbations.

ACR Appropriateness Criteria® Chronic Cough.

Chronic cough is defined by a duration lasting at least 8 weeks. The most common causes of chronic cough include smoking-related lung disease, upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. The etiology of chronic cough in some patients may be difficult to localize to an isolated source and is often multifactorial. The complex pathophysiology, clinical presentation, and variable manifestations of chronic cough underscore the challenges faced by clinicians in the evaluation and management of these patients. Imaging plays a role in the initial evaluation, although there is a lack of high-quality evidence guiding which modalities are useful and at what point in time the clinical evaluation should be performed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19.

BACKGROUND: Severe coronavirus disease 2019 (Covid-19) is associated with dysregulated inflammation. The effects of combination treatment with baricitinib, a Janus kinase inhibitor, plus remdesivir are not known. METHODS: We conducted a double-blind, randomized, placebo-controlled trial evaluating baricitinib plus remdesivir in hospitalized adults with Covid-19. All the patients received remdesivir (≤10 days) and either baricitinib (≤14 days) or placebo (control). The primary outcome was the time to recovery. The key secondary outcome was clinical status at day 15. RESULTS: A total of 1033 patients underwent randomization (with 515 assigned to combination treatment and 518 to control). Patients receiving baricitinib had a median time to recovery of 7 days (95% confidence interval [CI], 6 to 8), as compared with 8 days (95% CI, 7 to 9) with control (rate ratio for recovery, 1.16; 95% CI, 1.01 to 1.32; P = 0.03), and a 30% higher odds of improvement in clinical status at day 15 (odds ratio, 1.3; 95% CI, 1.0 to 1.6). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination treatment and 18 days with control (rate ratio for recovery, 1.51; 95% CI, 1.10 to 2.08). The 28-day mortality was 5.1% in the combination group and 7.8% in the control group (hazard ratio for death, 0.65; 95% CI, 0.39 to 1.09). Serious adverse events were less frequent in the combination group than in the control group (16.0% vs. 21.0%; difference, -5.0 percentage points; 95% CI, -9.8 to -0.3; P = 0.03), as were new infections (5.9% vs. 11.2%; difference, -5.3 percentage points; 95% CI, -8.7 to -1.9; P = 0.003). CONCLUSIONS: Baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time and accelerating improvement in clinical status among patients with Covid-19, notably among those receiving high-flow oxygen or noninvasive ventilation. The combination was associated with fewer serious adverse events. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT04401579.).

Impact of a Central-Line Insertion Site Assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI).

OBJECTIVE: To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention. DESIGN: A pre- and postintervention, quasi-experimental quality improvement study. SETTING AND PARTICIPANTS: Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center. METHODS: We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014-January 2015) and the intervention period (April 2015-October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated. RESULTS: Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06-0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039). CONCLUSIONS: The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.

The Obesity Paradox in Kidney Disease: How to Reconcile it with Obesity Management.

Obesity, a risk factor for de novo chronic kidney disease (CKD), confers survival advantages in advanced CKD. This so-called obesity paradox is the archetype of the reverse epidemiology of cardiovascular risks, in addition to the lipid, blood pressure, adiponectin, homocysteine, and uric acid paradoxes. These paradoxical phenomena are in sharp contradistinction to the known epidemiology of cardiovascular risks in the general population. In addition to advanced CKD, the obesity paradox has also been observed in heart failure, chronic obstructive lung disease, liver cirrhosis, and metastatic cancer, as well as in the elderly. These are populations in whom protein-energy wasting and inflammation are strong predictors of early death. Both larger muscle mass and higher body fat provide longevity in these patients, whereas thinner body habitus and weight loss are associated with higher mortality. Muscle mass appears to be superior to body fat in conferring an even greater survival. The obesity paradox may be the result of a time discrepancy between competing risk factors, i.e., overnutrition as the long-term killer versus undernutrition as the short-term killer. Hemodynamic stability of obesity, lipoprotein defense against circulating endotoxins, protective cytokine profiles, toxin sequestration of fat mass, and antioxidation of muscle may play important roles. Despite claims that obesity paradox is a statistical fallacy and a result of residual confounding, the consistency of data and other causality clues suggest a high biologic plausibility. Examining the causes and consequences of the obesity paradox may help discover important pathophysiologic mechanisms leading to improved outcomes in patients with CKD.

Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: Findings from five University of California medical centers.

BACKGROUND: Almost 700 patients suffered from hospital-associated venous thromboembolism (HA-VTE) across 5 University of California hospitals in calendar year 2011. OBJECTIVE: Optimize venous thromboembolism (VTE) prophylaxis (VTEP) in adult medical/surgical inpatients and reduce HA-VTE by at least 20% within 3 years. DESIGN: Prospective, unblinded, open-intervention study with historical controls. SETTING: Five independent but cooperating academic hospitals. PATIENTS: All adult medical and surgical inpatients with stays ≥3 days. The baseline year was 2011, 2012 to 2014 were intervention years, and year 2014 was the mature comparison period. VTEP adequacy was assessed with structured chart review of 45 patients per month at each site via random selection beginning partway through the study. HA-VTE was identified by discharge coding, capturing patients readmitted within 30 days of prior VTE-free admit and VTE occurring during index admission. Cases were stratified medical versus surgical and cancer or noncancer. INTERVENTIONS: Interventions included structured order sets with "3-bucket" risk-assessment, measure-vention, techniques to improve reliable administration of VTEP, and education. RESULTS: Adequate prophylaxis reached 89% by early 2014. The rate of HA-VTE fell from 0.90% in 2011 to 0.69% in 2014 (24% relative risk [RR] reduction; RR: 0.76, 95% confidence interval: 0.68-0.852), equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. VTE rates were highest in cancer and surgical patients. CONCLUSIONS: Hospital systems can reduce HA-VTE by implementing a bundle of active interventions including structured VTEP orders with embedded risk assessment and measure-vention. Journal of Hospital Medicine 2016;11:S22-S28. © 2016 Society of Hospital Medicine.

Reverse Epidemiology of Traditional Cardiovascular Risk Factors in the Geriatric Population.

Traditional risk factors of cardiovascular death in the general population, including body mass index (BMI), serum cholesterol, and blood pressure (BP), are also found to relate to outcomes in the geriatric population, but in an opposite direction. Some degrees of elevated BMI, serum cholesterols, and BP are reportedly associated with lower, instead of higher, risk of death among the elderly. This phenomenon is termed "reverse epidemiology" or "risk factor paradox" (such as obesity paradox) and is also observed in a variety of chronic disease states such as end-stage renal disease requiring dialysis, chronic heart failure, rheumatoid arthritis, and AIDS. Several possible causes are hypothesized to explain this risk factor reversal: competing short-term and long-term killers, improved hemodynamic stability in the obese, adipokine protection against tumor necrosis factor-α, lipoprotein protection against endotoxins, and lipophilic toxin sequestration by the adipose tissue. It is possible that the current thresholds for intervention and goal levels for such traditional risk factors as BMI, serum cholesterol, and BP derived based on younger populations do not apply to the elderly, and that new levels for such risk factors should be developed for the elderly population. Reverse epidemiology of conventional cardiovascular risk factors may have a bearing on the management of the geriatric population, thus it deserves further attention.

Comparison of hospital length of stay, costs, and readmissions of alteplase versus catheter replacement among patients with occluded central venous catheters.

BACKGROUND: Central venous catheter (CVC) occlusion is common, affecting 30% of all CVCs. OBJECTIVE: To compare length of stay (LOS), costs, and readmissions associated with the use of alteplase to clear catheter blockage to outcomes associated with catheter replacement. DESIGN: Retrospective observational study utilizing a large hospital database. PARTICIPANTS: Hospitalized patients treated for catheter occlusion from January 2006 to December 2011. MAIN MEASURES: Univariate analyses of patient characteristics and treatment patterns and multivariable regression analyses of postocclusion hospital costs, LOS, and 30- and 90-day readmissions were conducted. KEY RESULTS: We included 34,579 patients treated for a CVC occlusion by replacement (N=1028) or by alteplase (2 mg) administration (N=33,551). Patients receiving alteplase were somewhat younger than those having catheter replacement (60 ± 19 vs 62 ± 20 years old, P=0.0002). After adjusting for patient and hospital factors via regression modeling, average daily postocclusion costs were $317 lower for alteplase recipients than for catheter replacement patients (95% confidence interval [CI]: 238.22-392.24; P<0.0001). Adjusted total postocclusion costs were $1419 lower for alteplase recipients versus patients receiving catheter replacement (95% CI: 307.27-2458.12; P=0.0121). Postocclusion operating room/surgery, radiology, and supply costs were significantly lower for alteplase recipients (P<0.001). Average adjusted postocclusion LOS was similar for both groups (P>0.05). Odds of readmission were not significantly different at 30 or 90 days. CONCLUSIONS: Among patients treated for an occluded CVC, alteplase-treated patients had lower daily and total postocclusion costs than patients receiving catheter replacement. Cost differences were mainly driven by lower operating room/surgery, radiology, and supplier costs.

Duration of venous thromboembolism risk across a continuum in medically ill hospitalized patients.

BACKGROUND: Patients hospitalized for medical illness are at increased risk of venous thromboembolism (VTE), but the duration of risk is not well understood. OBJECTIVE: To assess incidence and time course of symptomatic VTE following hospitalization for medical illness in a large, real-world patient population. DESIGN: Data were extracted from the Thomson Reuters MarketScan(®) Inpatient Drug Link File. PATIENTS: Those hospitalized with cancer, heart failure, severe lung disease, or infectious disease from 2005 to 2008. MEASUREMENTS: The cumulative VTE risk over 180 days after admission was calculated using Kaplan-Meier analysis. VTE hazard was calculated on a daily basis and smoothed through LOESS regression. RESULTS: The analysis included 11,139 medically ill patients, 46.7% and 8.8% of whom received pharmacological thromboprophylaxis during hospitalization and after discharge, respectively. The mean duration of prophylaxis during hospitalization was 5.0 days. Of the 11,139 patients, 366 (3.3%) experienced a symptomatic VTE event. VTE events were most frequent during days 0-9 (97 events), followed by days 10-19 (82 events). The mean length of hospital stay was 5.3 days, and 56.6% of all VTE events occurred after discharge. VTE hazard peaked at day 8, with 1.05 events per 1000 person-days. CONCLUSIONS: The time course of VTE in medical patients shows that risk of symptomatic VTE is highest during the first 19 days after hospital admission, and extends into the period after discharge. Future research is warranted to investigate risks and benefits of reducing the incidence of VTE after discharge, including the role of improving thromboprophylaxis practices in the inpatient setting and extending thromboprophylaxis after hospitalization.

Inpatient and outpatient occurrence of deep vein thrombosis and pulmonary embolism and thromboprophylaxis following selected at-risk surgeries.

BACKGROUND: Despite evidence-based guidelines on prevention, many surgical patients remain at risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). OBJECTIVE: To quantify the provision of thromboprophylaxis and proportion of US surgical patients who develop DVT/PE, both in the hospital and postdischarge. METHODS: This study was an observational, retrospective database analysis of national managed care data. Data were extracted from the Premier Perspective-i3 Pharma Informatics linked database on patients hospitalized between January 2005 and November 2007 for orthopedic surgery or major abdominal surgery. Patients were included if they were aged 18 years or older at the time of hospitalization and had at least 6 months of continuous plan enrollment prior to index hospitalization. Patients discharged to an acute care facility or with atrial fibrillation were excluded. Prophylaxis status was evaluated during index hospitalization and for 14 days postdischarge. The proportion of patients who developed DVT/PE was calculated during index hospitalization and for 30 days postdischarge. RESULTS: The analysis included 19,581 patients following major abdominal surgery and 5315 patients following orthopedic surgery. Inpatient pharmacologic or mechanical thromboprophylaxis was received by 58.7% of abdominal surgery patients and 85.0% of orthopedic surgery patients; outpatient pharmacologic prophylaxis was received by 1.6% and 58.4% of patients, respectively. Total mean (SD) prophylaxis duration was 1.7 (3.7) days following abdominal surgery and 13.0 (11.6) days following orthopedic surgery. The proportion of abdominal surgery patients who developed symptomatic DVT/PE was 1.6%; 3.1% of orthopedic surgery patients developed symptomatic DVT/PE, with almost 40% of the events occurring postdischarge. CONCLUSIONS: Continued efforts are needed to prevent DVT/PE after abdominal and orthopedic surgery. Initiatives that encourage outpatient prophylaxis must ensure that appropriate prophylaxis of adequate duration is prescribed to all at-risk surgical patients to further reduce DVT/PE across the continuum of care. Pharmacists can play an important role in optimizing continuity of patient care in the prevention of DVT, in providing anticoagulation services that can help reduce the incidence of DVT/PE and bleeding complications, and in helping hospitals achieve performance measures.

Retrospective administrative database study of the time period of venous thromboembolism risk during and following hospitalization for major orthopedic or abdominal surgery in real-world US patients.

PURPOSE: To assess the incidence and time course of symptomatic venous thromboembolism (VTE) events in patients during and following hospitalization for major orthopedic or abdominal surgery. METHODS: Data were extracted from the Thomson Reuters MarketScan(®) Inpatient Drug Link File for surgical patients admitted between January 2005 and December 2008. The analysis included 8989 abdominal surgery patients and 4220 orthopedic surgery patients. The cumulative risks of VTE and VTE hazard were assessed over a 180-day evaluation period after the hospital admission date, using Kaplan-Meier analysis and LOESS regression, respectively. RESULTS: In total, 305 (2.3%) patients experienced a symptomatic VTE event. These were most frequent during days 1-9 (78 events) and 10-19 (72 events). In all, 64% of events occurred after discharge. Venous thromboembolism hazard peaked at approximately 1.3 per 1000 person-days (day 8) following orthopedic surgery and at approximately 0.52 per 1000 person-days (day 11) following abdominal surgery. In-hospital pharmacologic prophylaxis was received by 88.3% and 30.2% of orthopedic and abdominal surgery patients, respectively, whereas pharmacologic prophylaxis following hospitalization was received by 41.3% and 3.0% of patients, respectively. CONCLUSIONS: The time course of VTE in major surgery patients suggests that VTE risk is highest during the first 19 days after admission and that considerable VTE risk extends into the period after discharge.

Real-world rates of in-hospital and postdischarge deep-vein thrombosis and pulmonary embolism in at-risk medical patients in the United States.

Hospitalized medical patients are at risk of deep-vein thrombosis (DVT) and pulmonary embolism (PE). We evaluated inpatient and postdischarge DVT/PE and thromboprophylaxis rates in US medical patients, using patient admissions from January 2005 to November 2007 in the Premier Perspective™-i3 Pharma Informatics database. Among 15 721 patients with cancer, congestive heart failure, severe lung disease, and infectious disease, 39.0% received inpatient thromboprophylaxis, with the highest rate in patients with cancer (51.9%). In all, 3.4% received outpatient pharmacological prophylaxis. Mean ± SD prophylaxis duration was 2.2 ± 5.7 days. Overall, 3.0% of inpatients had symptomatic DVT/PE, and an additional 1.1% of patients were rehospitalized for DVT/PE or treated in the outpatient setting. Patients with infectious disease had the highest rate of DVT/PE (4.6%). Inpatient DVT/PE and prophylaxis rates of the different medical conditions had a negative correlation (R(2) = 0.72). This analysis demonstrates the burden of DVT/PE and highlights the underuse of thromboprophylaxis across the continuum of care.

Does ambulation modify venous thromboembolism risk in acutely ill medical patients?

In the US, ambulatory status is often a criterion for stopping prophylaxis for venous thromboembolism (VTE). In an analysis of the prophylaxis in MEDical patients with ENOXaparin (MEDENOX) trial, ambulatory status was assessed as outcome and patients grouped accordingly for further analysis. Rates of VTE and bleeding were evaluated. Using multivariate logistic regression, the relationships between thromboprophylaxis, VTE risk, and ambulatory status were assessed. Ambulatory status was reached in 607/1,084 patients, in a mean time of 4.4 days. Thromboprophylaxis was provided for 7.3 and 7.7 days in the ambulatory and non-ambulatory groups. Although VTE rates were lower in ambulatory patients, enoxaparin 40 mg once daily significantly reduced the risk of VTE vs. placebo in ambulatory (3.3% vs. 10.6%; relative risk [RR] = 0.31; 95% confidence interval [CI], 0.13-0.78; p=0.008) and non-ambulatory patients (9.0% vs. 19.7%; RR = 0.46; 95% CI, 0.23-0.91; p=0.02). Major bleeding was not significantly different between enoxaparin and placebo in either group. By multivariate regression analysis, VTE risk in ambulatory patients was lower with enoxaparin vs. placebo (odds ratio [OR] = 0.28; 95% CI, 0.11-0.74; p=0.01), but higher in patients with a history of VTE (OR = 3.74; 95% CI, 1.59-8.84; p=0.003) or cancer (OR = 2.12; 95% CI, 1.00-4.48; p=0.049). Despite timely mobilisation, patients who become ambulatory are at VTE risk and experience a significant risk reduction with enoxaparin 40 mg. Therefore, it is essential that ambulatory patients receive recommended thromboprophylaxis.

Need to improve thromboprophylaxis across the continuum of care for surgical patients.

INTRODUCTION: Prophylaxis for venous thromboembolism (VTE) is underused following major surgery and frequently stopped at hospital discharge despite short stays and high VTE risk for several weeks postsurgery. We evaluated inpatient and postdischarge prophylaxis in patients who underwent major abdominal or orthopedic surgery. METHODS: Patient records were assessed for anticoagulant use by cross-matching data from the Premier's Perspective discharge database with the i3/Ingenix LabRx outpatient and inpatient database from January 2005 to December 2007. Abdominal or orthopedic surgery patients at risk of VTE according to the 2004 American College of Chest Physicians guidelines and with no contraindications to anticoagulation were included. RESULTS: A total of 14,009 eligible surgical discharges were analyzed. Only 27.9% of the 10,698 abdominal surgery patients received anticoagulation in hospital. Most inpatients received unfractionated heparin (12.3% of the total abdominal surgery population) or enoxaparin (11.8%). Of the 3311 orthopedic surgery patients, 91.1% received in-hospital anticoagulation. Similar proportions of patients received enoxaparin (32.1%), warfarin (31.1%), or other agents (28.0%). Only 1.2% of abdominal surgery patients had an anticoagulant prescription filled 30 days postdischarge. Although orthopedic surgery outpatients had higher anticoagulation rates, only 54.4% had filled a prescription 30 days postdischarge with 31.1% receiving warfarin, 18.5% receiving enoxaparin, and 4.8% receiving other anticoagulants. The higher prophylaxis rate in orthopedic patients may reflect the high VTE risk in orthopedic surgery patients and increased awareness among orthopedic surgeons. CONCLUSION: This real-world study highlights the underuse of thromboprophylaxis in hospitalized surgical patients, especially following abdominal surgery. Furthermore, a considerable proportion of these patients do not receive postdischarge anticoagulation despite guideline recommendations. Further efforts are needed to improve anticoagulant use, particularly in the outpatient setting.

Are There Any Differences in the Clinical and Economic Outcomes Between US Cancer Patients Receiving Appropriate or Inappropriate Venous Thromboembolism Prophylaxis?

Prophylaxis is often underused and inappropriately prescribed. This study compares the efficacy and cost of appropriate and partial prophylaxis in cancer patients at risk for VTE.

Prevention of venous thromboembolism in the hospitalized medical patient.

Hospitalized acutely ill medical patients are at high risk for venous thromboembolism (VTE), and clinical trials clearly demonstrate that pharmacologic prophylaxis of VTE for up to 14 days significantly reduces the incidence of VTE in this population. Guidelines recommend use of low-molecular-weight heparin (LMWH) or unfractionated heparin (5,000 U three times daily) for VTE prophylaxis in hospitalized medical patients with risk factors for VTE; in patients with contraindications to anticoagulants, mechanical prophylaxis is recommended. All hospitalized medical patients should be assessed for their risk of VTE at admission and daily thereafter, and those with reduced mobility and one or more other VTE risk factors are candidates for aggressive VTE prophylaxis. Based on results from the recently reported EXCLAIM trial, extended postdischarge prophylaxis with LMWH for 28 days should be considered for hospitalized medical patients with reduced mobility who are older than age 75 or have a cancer diagnosis or a history of VTE.