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Background: Cancer-associated venous thromboembolism (CA-VTE) represents a major cause of morbidity and mortality in patients with cancer. Despite poor outcomes, there is an ongoing knowledge gap in epidemiologic data related to this association. Objectives: To compare venous thromboembolism (VTE) characteristics, risk factors, and outcomes between patients with and without active cancer in a racially diverse population. Methods: Our surveillance project occurred at the 3 hospitals in Durham County, North Carolina, from April 2012 through March 2014. Electronic and manual methods were used to identify unique Durham County residents with VTE. Results: We identified 987 patients with VTE during the surveillance period. Of these, 189 patients had active cancer at the time of their VTE event. Patients with CA-VTE were older (median age: 69 years vs 60 years, P < .0001) and had a lower body mass index (median body mass index: 26.0 kg/m2 vs 28.4 kg/m2, P = .0001) than noncancer patients. The most common cancers in our cohort were gastrointestinal, breast, genitourinary, and lung. The proportion of VTE cases with pulmonary embolism (PE) was greater in the cancer cohort compared with that in the noncancer cohort (58.2% vs 44.0%, P = .0004). Overall survival was lower in the CA-VTE group than in patients without cancer (P < .0001). Black patients with CA-VTE had lower proportion of PE (52.3% vs 67.1%, P = .05) but had decreased survival (P < .0003) in comparison with White patients. Conclusion: Future studies may be needed to continue to evaluate local and national VTE data to improve VTE prevention strategies and CA-VTE outcomes.
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Background: Venous thromboembolism (VTE) affects approximately 1-2 individuals per 1000 annually and is associated with an increased risk for pulmonary hypertension, postthrombotic syndrome, and recurrent VTE. Objective: To determine risk factors, incidence, treatments, and outcomes of VTE through a 2-year surveillance program initiated in Durham County, North Carolina (population approximately 280,000 at time of study). Patients/Methods: We performed a retrospective analysis of data actively collected from three hospitals in Durham County during the surveillance period. Results: A total of 987 patients were diagnosed with VTE, for an annual rate of 1.76 per 1000 individuals. Hospital-associated VTE occurred in 167 hospitalized patients (16.9%) and 271 outpatients who were hospitalized within 90 days of diagnosis (27.5%). Annual incidence was 1.98 per 1000 Black individuals compared to 1.25 per 1000 White individuals (p < 0.0001), and Black individuals with VTE were younger than White individuals (p < 0.0001). Common risk factors included active cancer, prolonged immobility, and obesity, and approximately half were still taking anticoagulant therapy 1 year later. A total of 224 patients died by 1 year (28.5% of patients for whom outcomes could be confirmed), and Black patients were more likely to have recurrent VTE than White patients during the first 6 months following initial presentation (9.4% vs. 4.1%, p = 0.01). Conclusions: Ongoing surveillance provides an effective strategy to identify patients with VTE and monitor treatment and outcomes. We demonstrated that hospital-associated VTE continues to be a major contributor to the burden of VTE and confirmed the higher incidence of VTE in Black compared to White individuals.
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IMPORTANCE: The benefit of an electronic support system for the prescription and adherence to oral anticoagulation therapy among patients with atrial fibrillation (AF) and atrial flutter at heightened risk for of stroke and systemic thromboembolism is unclear. OBJECTIVE: To evaluate the effect of a combined alert intervention and shared decision-making tool to improve prescription rates of oral anticoagulation therapy and adherence. DESIGN, SETTING, AND PARTICIPANTS: A prospective single arm study of 939 consecutive patients treated at a large tertiary healthcare system. EXPOSURES: An electronic support system comprising 1) an electronic alert to identify patients with AF or atrial flutter, a CHA2DS2-VASc score ≥ 2, and not on oral anticoagulation and 2) electronic shared decision-making tool to promote discussions between providers and patients regarding therapy. MAIN OUTCOMES AND MEASURES: The primary endpoint was prescription rate of anticoagulation therapy. The secondary endpoint was adherence to anticoagulation therapy defined as medication possession ratio ≥ 80% during the 12 months of follow-up. RESULTS: Between June 13, 2018 and August 31, 2018, the automated intervention identified and triggered a unique alert for 939 consecutive patients with AF or atrial flutter, a CHA2DS2-VASc score ≥2 who were not on oral anticoagulation. The median CHA2DS2-VASc score among all patients identified by the alert was 2 and the median untreated duration prior to the alert was 495 days (interquartile range 123 - 1,831 days). Of the patients identified by the alert, 345 (36.7%) initiated anticoagulation therapy and 594 (63.3%) did not: 68.7% were treated with a non-Vitamin K antagonist oral anticoagulant (NOAC), 22.0% with warfarin, and 9.3 % combination of NOAC and warfarin. Compared with historical anticoagulation rates, the electronic alert was associated with a 23.6% increase in anticoagulation prescriptions. The overall 1-year rate of adherence to anticoagulant therapy was 75.4% (260/345). CONCLUSION AND RELEVANCE: An electronic automated alert can successfully identify patients with AF and atrial flutter at high risk for stroke, increase oral anticoagulation prescription, and support high rates of adherence.
Subject(s)
Atrial Fibrillation , Stroke , Administration, Oral , Anticoagulants , Atrial Fibrillation/complications , Atrial Fibrillation/drug therapy , Electronics , Humans , Prospective Studies , Risk Assessment , Risk Factors , Stroke/chemically induced , Stroke/prevention & control , WarfarinABSTRACT
Patients with coronavirus disease 2019 (COVID-19) are at heightened risk of venous thromboembolic events (VTE), though there is no data examining when these events occur following a COVID-19 diagnosis. We therefore sought to characterize the incidence, timecourse of events, and outcomes of VTE during the COVID-19 pandemic in a national healthcare system using data from Veterans Affairs Administration.
Subject(s)
Anticoagulants/administration & dosage , COVID-19 , Venous Thromboembolism , Veterans Health/statistics & numerical data , Aged , COVID-19/complications , COVID-19/epidemiology , COVID-19/therapy , COVID-19 Nucleic Acid Testing , Chemoprevention/methods , Chemoprevention/statistics & numerical data , Female , Hospitalization/statistics & numerical data , Humans , Incidence , Male , Outcome Assessment, Health Care , Risk Assessment/statistics & numerical data , Risk Factors , SARS-CoV-2/isolation & purification , United States/epidemiology , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Venous Thromboembolism/therapyABSTRACT
BACKGROUND The long-term safety of paclitaxel-coated devices (PCDs; drug-coated balloon or drug-eluting stent) for peripheral endovascular intervention is uncertain. We used data from the Veterans Health Administration to evaluate the association between PCDs, long-term mortality, and cause of death. METHODS AND RESULTS Using the Veterans Administration Corporate Data Warehouse in conjunction with International Classification of Diseases, Tenth Revision (ICD-10) Procedure Coding System, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes, we identified patients with peripheral artery disease treated within the Veterans Administration for femoropopliteal artery revascularization between October 1, 2015, and June 30, 2019. An adjusted Cox regression, using stabilized inverse probability-weighted estimates, was used to evaluate the association between PCDs and long-term survival. Cause of death data were obtained using the National Death Index. In total, 10 505 patients underwent femoropopliteal peripheral endovascular intervention; 2265 (21.6%) with a PCD and 8240 (78.4%) with a non-PCD (percutaneous angioplasty balloon and/or bare metal stent). Survival rates at 2 years (77.4% versus 79.7%) and 3 years (70.7% versus 71.8%) were similar between PCD and non-PCD groups, respectively. The adjusted hazard for all-cause mortality for patients treated with a PCD versus non-PCD was 1.06 (95% CI, 0.95-1.18, P=0.3013). Among patients who died between October 1, 2015, and December 31, 2017, the cause of death according to treatment group, PCD versus non-PCD, was similar. CONCLUSIONS Among patients undergoing femoropopliteal peripheral endovascular intervention within the Veterans Administration Health Administration, there was no increased risk of long-term, all-cause mortality associated with PCD use. Cause-specific mortality rates were similar between treatment groups.
Subject(s)
Angioplasty, Balloon/methods , Drug-Eluting Stents , Femoral Artery/surgery , Paclitaxel/pharmacology , Popliteal Artery/surgery , Veterans Health , Veterans , Aged , Antineoplastic Agents, Phytogenic/pharmacology , Cause of Death/trends , Coated Materials, Biocompatible , Female , Follow-Up Studies , Humans , Lower Extremity , Male , Peripheral Arterial Disease/mortality , Retrospective Studies , Risk Factors , Treatment Outcome , United States , United States Department of Veterans Affairs/statistics & numerical dataABSTRACT
BACKGROUND: Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. OBJECTIVES: This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. METHODS: The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans' Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. RESULTS: Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. CONCLUSION: We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.
Subject(s)
Electronic Health Records , Population Surveillance/methods , Venous Thromboembolism/diagnosis , Autopsy , Data Mining , Geography , Hospitals/statistics & numerical data , Humans , Venous Thromboembolism/pathologyABSTRACT
BACKGROUND: The relationship between body mass index (BMI) and cardiopulmonary adverse events (CAEs) for ambulatory colonoscopy is unclear. AIM: To assess the association of BMI and CAEs associated with ambulatory colonoscopy. METHODS: This is a retrospective cohort analysis of 418 patients who underwent outpatient colonoscopy at the Durham Veterans Affairs Medical Center categorized as normal/overweight (BMI < 30), obese (BMI 30-34), or morbidly obese (BMI ≥ 35). Adjusted logistic regression analyses were performed. RESULTS: At least one CAE occurred in 46.4% of patients (220 events, 72.7% were hypoxia). The rate of CAEs (BMI < 30: 43.8%, BMI 30-34: 48.0%, BMI ≥ 35: 50.6%, p = 0.53) and rate of hypoxia (BMI < 30: 34.8%, BMI 30-34: 40.9%, BMI ≥ 35: 43.2%, p = 0.32) were numerically higher for obese and morbidly obese patients, but not statistically significant. Obese (OR 1.10, 95% CI 0.70-1.73) and morbidly obese (OR 1.07, 95% CI 0.61-1.85) patients did not have an increased risk of CAEs after adjusting for age, ASA class, obstructive sleep apnea (OSA), and type of sedation. OSA was independently associated with an increased risk of CAEs (OR 1.71, 95% CI 1.09-2.74, p = 0.02) after adjusting for BMI, age, ASA class, and type of sedation. CONCLUSION: OSA confers a higher risk of CAEs independent of BMI and sedation type. Consideration of undiagnosed OSA is recommended for appropriate pre-procedure risk stratification. While not statistically significant in this study, there may be clinically significant increased risks of CAEs and hypoxia for patient with BMI > 30 that require further evaluation with larger studies.
Subject(s)
Ambulatory Care , Body Mass Index , Colonoscopy/adverse effects , Heart Diseases/etiology , Lung Diseases/etiology , Obesity/complications , Sleep Apnea, Obstructive/complications , Aged , Chi-Square Distribution , Female , Heart Diseases/diagnosis , Humans , Logistic Models , Lung Diseases/diagnosis , Male , Middle Aged , Obesity/diagnosis , Odds Ratio , Retrospective Studies , Risk Assessment , Risk Factors , Sleep Apnea, Obstructive/diagnosis , United States , United States Department of Veterans AffairsABSTRACT
OBJECTIVES: We sought to characterize how the perceived risk of early dual antiplatelet therapy (DAPT) discontinuation is incorporated into operator decision-making regarding stent choice, using a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation. BACKGROUND: Understanding which factors influence operator decision-making regarding stent choice during percutaneous coronary intervention (PCI) could help identify areas for quality improvement. METHODS: We retrospectively identified 1202 patients who underwent PCI from July 2008 to January 2013 at the Durham Veterans Affairs Medical Center. We excluded patients without a complete pre-procedure survey within 14days of PCI, repeat procedures on the same patient and those who received both drug-eluting stents (DES) and bare-metal stents (BMS) or no stent during PCI, leaving 864 patients. The primary outcome was the independent association of "yes" responses to survey items with the odds of DES use during PCI. RESULTS: Of 864 patients, 661 received DES and 203 received BMS. A "yes" response to "planned major surgery or dental work in the next year" (OR 0.20, 95% CI 0.11-0.36, p<0.001), "recent bleeding event or bleeding diathesis" (OR 0.31, 95% CI 0.14-0.68, p=0.003) or "currently taking Coumadin" (OR 0.39, 95% CI 0.19-0.78, p=0.007) was independently associated with lower odds of DES use. CONCLUSIONS: Responses to 3 items on a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation were independently associated with stent type used during PCI, suggesting the importance of these factors in an operator's stent choice.
Subject(s)
Choice Behavior , Clinical Decision-Making , Drug-Eluting Stents , Metals , Percutaneous Coronary Intervention/instrumentation , Practice Patterns, Physicians' , Stents , Aged , Anticoagulants/adverse effects , Decision Support Techniques , Dentistry/methods , Drug Administration Schedule , Drug Therapy, Combination , Female , Health Care Surveys , Health Knowledge, Attitudes, Practice , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Percutaneous Coronary Intervention/adverse effects , Platelet Aggregation Inhibitors/administration & dosage , Prosthesis Design , Retrospective Studies , Risk Factors , Surgical Procedures, Operative/adverse effects , Time Factors , Treatment Outcome , United States , United States Department of Veterans Affairs , Warfarin/adverse effectsABSTRACT
Background Patient-physician communication is an integral part of high-quality patient care and an expectation of the Clinical Learning Environment Review program. Objective This quality improvement initiative evaluated the impact of an educational audit and feedback intervention on the frequency of use of 2 tools-business cards and white boards-to improve provider identification. Methods This before-after study utilized patient surveys to determine the ability of those patients to name and recognize their physicians. The before phase began in July 2013. From September 2013 to May 2014, physicians received education on business card and white board use. Results We surveyed 378 patients. Our intervention improved white board utilization (72.2% postintervention versus 54.5% preintervention, P < .01) and slightly improved business card use (44.4% versus 33.7%, P = .07), but did not improve physician recognition. Only 20.3% (14 of 69) of patients could name their physician without use of the business card or white board. Data from all study phases showed the use of both tools improved patients' ability to name physicians (OR = 1.72 and OR = 2.12, respectively; OR = 3.68 for both; P < .05 for all), but had no effect on photograph recognition. Conclusions Our educational intervention improved white board use, but did not result in improved patient ability to recognize physicians. Pooled data of business cards and white boards, alone or combined, improved name recognition, suggesting better use of these tools may increase identification. Future initiatives should target other barriers to usage of these types of tools.
Subject(s)
Inpatients/psychology , Physician-Patient Relations , Physicians , Quality Improvement , Adult , Hospitalists , Humans , Internship and Residency , Photography , Surveys and QuestionnairesABSTRACT
BACKGROUND: Guidance for appropriate utilisation of transthoracic echocardiograms (TTEs) can be incorporated into ordering prompts, potentially affecting the number of requests. METHODS: We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and American College of Cardiology Choosing Wisely list on TTE use for dyspnoea, oedema and valvular disease into electronic ordering systems at Durham Veterans Affairs Medical Center. Our primary outcome was TTE orders per month. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) ordering prior to TTE. Outcomes were measured for 20â months before and 12â months after the intervention. RESULTS: The number of TTEs ordered did not decrease (338±32 TTEs/month prior vs 320±33 afterwards, p=0.12). Rates of outpatient TTE ordering decreased minimally post intervention (2.28 per 100 primary care/cardiology visits prior vs 1.99 afterwards, p<0.01). Effects on TTE ordering and ordering rate significantly interacted with time from intervention (p<0.02 for both), as the small initial effects waned after 6â months. The percentage of TTE orders with preceding BNP increased (36.5% prior vs 42.2% after for inpatients, p=0.01; 10.8% prior vs 14.5% after for outpatients, p<0.01). CONCLUSIONS: Ordering prompts for TTEs initially minimally reduced the number of TTEs ordered and increased BNP measurement at a single institution, but the effect on TTEs ordered was likely insignificant from a utilisation standpoint and decayed over time.
Subject(s)
Decision Making, Computer-Assisted , Echocardiography/statistics & numerical data , Guideline Adherence/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Unnecessary Procedures/statistics & numerical data , Humans , Natriuretic Peptide, Brain/blood , Practice Patterns, Physicians'/standards , Tertiary Care Centers/statistics & numerical dataABSTRACT
BACKGROUND: It is unclear whether diagnostic protocols based on cardiac markers to identify low-risk chest pain patients suitable for early release from the emergency department can be applied to patients older than 65 years or with traditional cardiac risk factors. METHODS AND RESULTS: In a single-center retrospective study of 231 consecutive patients with high-risk factor burden in which a first cardiac troponin (cTn) level was measured in the emergency department and a second cTn sample was drawn 4 to 14 hours later, we compared the performance of a modified 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Using Contemporary Troponins as the Only Biomarker (ADAPT) rule to a new risk classification scheme that identifies patients as low risk if they have no known coronary artery disease, a nonischemic electrocardiogram, and 2 cTn levels below the assay's limit of detection. Demographic and outcome data were abstracted through chart review. The median age of our population was 64 years, and 75% had Thrombosis In Myocardial Infarction risk score ≥2. Using our risk classification rule, 53 (23%) patients were low risk with a negative predictive value for 30-day cardiac events of 98%. Applying a modified ADAPT rule to our cohort, 18 (8%) patients were identified as low risk with a negative predictive value of 100%. In a sensitivity analysis, the negative predictive value of our risk algorithm did not change when we relied only on undetectable baseline cTn and eliminated the second cTn assessment. CONCLUSIONS: If confirmed in prospective studies, this less-restrictive risk classification strategy could be used to safely identify chest pain patients with more traditional cardiac risk factors for early emergency department release.
Subject(s)
Acute Coronary Syndrome/diagnosis , Decision Support Techniques , Acute Coronary Syndrome/complications , Aged , Biomarkers/blood , Chest Pain/etiology , Electrocardiography , Emergency Service, Hospital , Female , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , Troponin C/bloodABSTRACT
The goal of this study was to evaluate general medicine physicians' ability to predict hospital discharge. We prospectively asked study subjects to predict whether each patient under their care would be discharged on the next day, on the same day, or neither. Discharge predictions were recorded at 3 time points: mornings (7-9 am), midday (12-2 pm), or afternoons (5-7 pm), for a total of 2641 predictions. For predictions of next-day discharge, the sensitivity (SN) and positive predictive value (PPV) were lowest in the morning (27% and 33%, respectively), but increased by the afternoon (SN 67%, PPV 69%). Similarly, for same-day discharge predictions, SN and PPV were highest at midday (88% and 79%, respectively). We found that although physicians have difficulty predicting next-day discharges in the morning prior to the day of expected discharge, their ability to correctly predict discharges continually improved as the time to actual discharge decreased. Journal of Hospital Medicine 2015;10:808-810. © 2015 Society of Hospital Medicine.
Subject(s)
Clinical Competence/standards , General Practice/methods , General Practice/standards , Patient Discharge/standards , Physicians/standards , Forecasting , Humans , Prospective StudiesABSTRACT
The loss of Gimap5 (GTPase of the immune-associated protein 5) gene function is the underlying cause of lymphopenia and autoimmune diabetes in the BioBreeding (BB) rat. The in vivo function of murine gimap5 is largely unknown. We show that selective gene ablation of the mouse gimap5 gene impairs the final intrathymic maturation of CD8 and CD4 T cells and compromises the survival of postthymic CD4 and CD8 cells, replicating findings in the BB rat model. In addition, gimap5 deficiency imposes a block of natural killer (NK)- and NKT-cell differentiation. Development of NK/NKT cells is restored on transfer of gimap5(-/-) bone marrow into a wild-type environment. Mice lacking gimap5 have a median survival of 15 weeks, exhibit chronic hepatic hematopoiesis, and in later stages show pronounced hepatocyte apoptosis, leading to liver failure. This pathology persists in a Rag2-deficient background in the absence of mature B, T, or NK cells and cannot be adoptively transferred by transplanting gimap5(-/-) bone marrow into wild-type recipients. We conclude that mouse gimap5 is necessary for the survival of peripheral T cells, NK/NKT-cell development, and the maintenance of normal liver function. These functions involve cell-intrinsic as well as cell-extrinsic mechanisms.
Subject(s)
Cell Survival , GTP Phosphohydrolases/physiology , GTP-Binding Proteins/physiology , Liver Failure/etiology , Natural Killer T-Cells/pathology , T-Lymphocytes/pathology , Animals , CD4-Positive T-Lymphocytes , CD8-Positive T-Lymphocytes , Cell Differentiation/immunology , GTP-Binding Proteins/deficiency , Liver Failure/immunology , Liver Failure/pathology , Mice , Mice, Mutant StrainsABSTRACT
Stem cells play a critical role in normal tissue maintenance, and mutations in these stem cells may give rise to cancer. We hypothesize that melanoma develops from a mutated stem cell and therefore residual stem cell characteristics should be able to be identified in melanoma cell lines. We studied three metastatic melanoma cell lines that exhibited multiple morphologic forms in culture and demonstrated the capacity to pigment. We used the ability to efflux Hoechst 33342 dye, a technique known to enrich for stem cells in many tissues, to segregate cell populations. The cells with the greatest ability to efflux the dye were (1) small in size, (2) had the capacity to give rise to larger cell forms, and (3) had the greatest ability to expand in culture. The small cells were found to have a decreased proliferative rate and were less melanized. Large dendritic cells that appeared to be nonproliferative were identified in cultures. Treatment with cytosine beta-D-arabinofuranoside hydrochloride (Ara-C) expanded the large cell population but the residual proliferative capacity, both in vitro and in vivo, remained concentrated in the smaller cell fraction. Antigenic staining patterns were variable and heterogeneous. Nestin (a neural stem cell marker) and gp100 (premelanosomal marker) favored the smaller cell population, while nerve growth factor receptor often labeled larger cells. Morphologic and antigenic heterogeneity remained intact after clonal purification. These findings are consistent with the behavior expected for a tumor based on stem cell biology; this finding has diagnostic and therapeutic implications for melanocytic neoplasias.