Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative.

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Race, Pain, and Beliefs Associated with Interest in Complementary and Alternative Medicine among Inner City Veterans.

OBJECTIVE: To investigate the prevalence and determinants of complementary and alternative medicine (CAM) interest level among a racially diverse cohort of inner city veterans who receive primary care at the VA Medical Center. DESIGN: Cross-sectional survey study SETTING: Philadelphia VA Medical Center SUBJECTS: Primary care patients (n = 258) METHODS: Interest in CAM was measured using a single item question. Patient treatment beliefs were assessed using validated instruments. We evaluated factors associated with patient interest in CAM using a multivariate logistic regression model. RESULTS: In this sample of 258 inner city primary care VA patients, interest in CAM was high 80% (n = 206). Interest in CAM was strongly associated with African American race [adjusted odds ratio (AOR) 2.19, 95% Confidence Interval (CI) 1.05-4.60, P = 0.037], higher levels of education (AOR 4.33, 95% CI 1.80-10.40, P = 0.001), presence of moderate to severe pain (AOR 2.02, 95% CI 1.02-4.78, P = 0.043), and expectations of benefit from CAM use (AOR 1.21, 95% CI 1.06-1.36, P = 0.004). CONCLUSIONS: CAM approaches have broad appeal within this inner city cohort of veterans, particularly among African Americans, those that experience pain and those that expect greater benefit from CAM. These findings may inform the development of patient-centered integrative pain management for veterans.

US veterans use vitamins and supplements as substitutes for prescription medication.

BACKGROUND: Vitamins and supplements are the most commonly used form of complementary and alternative medicine in the United States. Growing research suggests that patients substitute vitamins and supplements for their prescription medications. The reasons might include cost of prescription medications and discordant patient and doctor health belief systems. OBJECTIVES: To investigate the prevalence of substitution of vitamins and supplements for prescription medications among veterans who receive care in the VA health care system and whether substitution is associated with prescription rationing due to cost, treatment beliefs, or distrust of the health system. RESEARCH DESIGN: Cross-sectional observational survey. SUBJECTS: Primary care patients (n=275) at the Philadelphia VA Medical Center. MEASURES: Medication substitution, prescription medication rationing, treatment beliefs, and health system distrust were measured with structured instruments. Multivariate logistic regression was performed with substitution as the dependent variable. RESULTS: A significant number of primary care patients in the VA system use vitamins and supplements 206 (75%). The prevalence of medication substitution is high 48 (18%). Medication substitution is strongly associated with prescription rationing due to cost (adjusted odds ratio 6.3, 95% confidence interval: 2.0-19.5, P=0.001). Similarly, greater belief in complementary and alternative approaches to care positively predicts medication substitution (adjusted odds ratio 1.08, 95% confidence interval: 1.01-1.15, P=0.011). There is no significant association between health system distrust and likelihood of medication substitution. CONCLUSIONS: Medication substitution is prevalent in this sample of inner city primary care patients who receive care in the VA system. Cost of prescriptions and belief in the value of complementary and alternative approaches to care appear to be associated with this patient-driven treatment decision.