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Lutsey PL, Walker RF, MacLehose RF, Norby FL, Evensen LH, Alonso A, Zakai NA. Inpatient Versus Outpatient Acute Venous Thromboembolism Management: Trends and Postacute Healthcare Utilization From 2011 to 2018. J Am Heart Assoc 2021; 10:e020428. [PMID: 34622678 PMCID: PMC8751864 DOI: 10.1161/jaha.120.020428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Acute outpatient management of venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep vein thrombosis (DVT), is perceived to be as safe as inpatient management in some settings. How widely this strategy is used is not well documented. Methods and Results Using MarketScan administrative claims databases for years 2011 through 2018, we identified patients with International Classification of Diseases (ICD) codes indicating incident VTE and trends in the use of acute outpatient management. We also evaluated healthcare utilization and hospitalized bleeding events in the 6 months following the incident VTE event. A total of 200 346 patients with VTE were included, of whom 50% had evidence of PE. Acute outpatient management was used for 18% of those with PE and 57% of those with DVT only, and for both DVT and PE its use increased from 2011 to 2018. Outpatient management was less prevalent among patients with cancer, higher Charlson comorbidity index scores, and whose primary treatment was warfarin as compared with a direct oral anticoagulant. Healthcare utilization in the 6 months following the incident VTE event was generally lower among patients managed acutely as outpatients, regardless of initial presentation. Acute outpatient management was associated with lower hazard ratios of incident bleeding risk for both patients who initially presented with PE (0.71 [95% CI, 0.61, 0.82]) and DVT only (0.59 [95% CI, 0.54, 0.64]). Conclusions Outpatient management of VTE is increasing. In the present analysis, it was associated with lower subsequent healthcare utilization and fewer bleeding events. However, this may be because healthier patients were managed on an outpatient basis.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Rob F Walker
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Richard F MacLehose
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Faye L Norby
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Line H Evensen
- K.G. Jebsen - Thrombosis Research and Expertise Center (TREC) Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway
| | - Alvaro Alonso
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA
| | - Neil A Zakai
- Division of Hematology/Oncology Department of Medicine and Department of Pathology and Laboratory Medicine Larner College of Medicine at the University of Vermont Burlington VT
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Kennelty KA, Coffey CS, Ardery G, Uribe L, Yankey J, Ecklund D, James PA, Vander Weg MW, Chrischilles EA, Christensen AJ, Polgreen LA, Gryzlak B, Carter BL. A cluster randomized trial to evaluate a centralized remote clinical pharmacy service in large, health system primary care clinics. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Korey A. Kennelty
- Department of Pharmacy Practice and Science College of Pharmacy, University of Iowa Iowa City Iowa USA
- Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa USA
| | - Christopher S. Coffey
- Department of Biostatistics College of Public Health, University of Iowa Iowa City Iowa USA
| | - Gail Ardery
- Department of Pharmacy Practice and Science College of Pharmacy, University of Iowa Iowa City Iowa USA
| | - Liz Uribe
- Department of Biostatistics College of Public Health, University of Iowa Iowa City Iowa USA
| | - Jon Yankey
- Department of Biostatistics College of Public Health, University of Iowa Iowa City Iowa USA
| | - Dixie Ecklund
- Department of Biostatistics College of Public Health, University of Iowa Iowa City Iowa USA
| | - Paul A. James
- Department of Family Medicine University of Washington Seattle USA
| | - Mark W. Vander Weg
- Department of Psychology College of Liberal Arts, University of Iowa Iowa City Iowa USA
- Department of Internal Medicine Roy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa USA
- Iowa City Veterans Administration Iowa City Iowa USA
| | | | - Alan J. Christensen
- Department of Psychology College of Liberal Arts, University of Iowa Iowa City Iowa USA
- Department of Internal Medicine Roy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa USA
| | - Linnea A. Polgreen
- Department of Pharmacy Practice and Science College of Pharmacy, University of Iowa Iowa City Iowa USA
| | - Brian Gryzlak
- Department of Epidemiology College of Public Health, University of Iowa Iowa City Iowa USA
| | - Barry L. Carter
- Department of Pharmacy Practice and Science College of Pharmacy, University of Iowa Iowa City Iowa USA
- Department of Family Medicine Roy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa USA
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Musco SE, Smallwood SM, Gossard J. Development and Evaluation of a Pharmacist-Driven Screening Tool to Identify Patients Presenting to the Emergency Department Who Are Eligible for Outpatient Treatment of Deep Vein Thrombosis. J Pharm Pract 2019; 34:378-385. [PMID: 33969771 DOI: 10.1177/0897190019872582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a critical and costly health issue. Treatment in the outpatient setting is preferred compared to the inpatient setting. However, there is a lack of evidence regarding how best to identify patients who are ideal for outpatient DVT treatment. OBJECTIVE To design and evaluate a pharmacist-driven screening tool for the identification of patients presenting to the emergency department (ED) at a community hospital with DVT who are appropriate for outpatient treatment. METHODS This study was conducted in sequential phases: compilation and vetting of screening criteria, descriptive evaluation of criteria through retrospective chart review, and quantification of potential cost savings by avoiding admissions. Criteria were collected via literature search and assembled into a screening tool, which was applied retroactively to a cohort of ED patients admitted with DVT diagnosis. RESULTS A screening tool was developed with multidisciplinary input and consisted of 5 categories with individual patient and disease state criteria. The majority (91%) of patients reviewed would not have qualified for outpatient DVT treatment based on the retrospective application of the screening tool. The most common disqualification criteria category was high risk of bleeding/clotting (n = 81), and the most frequently represented parameter within that category was antithrombotic therapy prior to admission (n = 53). CONCLUSION A screening tool may not be the most efficient method for health-care practitioners such as pharmacists to identify ED patients appropriate for outpatient management of DVT. Other avenues should be explored for improving the cost-effective management of these patients.
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Affiliation(s)
- Shaina E Musco
- 465018High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC, USA
| | | | - Jill Gossard
- Pharmacy Department, Community Howard Regional Hospital, Kokomo, IN, USA
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Nagler M, ten Cate H, Prins MH, ten Cate‐Hoek AJ. Risk factors for recurrence in deep vein thrombosis patients following a tailored anticoagulant treatment incorporating residual vein obstruction. Res Pract Thromb Haemost 2018; 2:299-309. [PMID: 30046732 PMCID: PMC6055496 DOI: 10.1002/rth2.12079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/21/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Finding the optimal duration of anticoagulant treatment following an acute event of deep vein thrombosis (DVT) is challenging. Residual venous obstruction (RVO) has been identified as a risk factor for recurrence, but data on management strategies incorporating the presence of RVO and associated recurrence rates in defined clinical care pathways (CCP) are lacking. OBJECTIVES We aimed to investigate the long-term clinical outcomes and predictors of venous thromboembolism (VTE) recurrence in a contemporary cohort of patients with proximal DVT and managed in a CCP incorporating the presence of RVO. PATIENTS All patients treated at the Maastricht University Medical Center within an established clinical care pathway from June 2003 through June 2013 were prospectively followed for up to 11 years in a prospective management study. RESULTS Of 479 patients diagnosed with proximal DVT, 474 completed the two-year CCP (99%), and 457 (94.7%) the extended follow-up (2231.2 patient-years; median follow-up 4.6 years). Overall VTE recurrence was 2.9 per 100 patient-years, 1.3 if provoked by surgery, 2.1 if a non-surgical transient risk factor was present and 4.0 if unprovoked. Predictors of recurrent events were unprovoked VTE (adjusted hazard ratio [HR] 4.6; 95% CI 1.7, 11.9), elevated D-dimer one month after treatment was stopped (HR 3.3; 1.8, 6.1), male sex (HR 2.8; 1.5, 5.1), high factor VIII (HR 2.2; 1.2, 4.0) and use of contraceptives (HR 0.1; 0.0, 0.9). CONCLUSIONS Patients with DVT managed within an established clinical care pathway incorporating the presence of RVO had relatively low incidences of VTE recurrence.
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Affiliation(s)
- Michael Nagler
- Department of Hematology and Central Hematology LaboratoryInselspital University HospitalBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Hugo ten Cate
- Thrombosis Expertise Center and Laboratory of Clinical Thrombosis and Hemostasis, and Cardiovascular Research InstituteMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Martin H. Prins
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Arina J. ten Cate‐Hoek
- Thrombosis Expertise Center and Laboratory of Clinical Thrombosis and Hemostasis, and Cardiovascular Research InstituteMaastricht University Medical CenterMaastrichtThe Netherlands
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Al-Hameed FM, Al-Dorzi HM, Al-Momen AM, Algahtani FH, Al-Zahrani HA, Al-Saleh KA, Al-Sheef MA, Owaidah TM, Alhazzani W, Neumann I, Wiercioch W, Brozek J, Schunemann H, Akl EA. The Saudi Clinical Practice Guideline for the treatment of venous thromboembolism. Outpatient versus inpatient management. Saudi Med J 2016. [PMID: 26219456 PMCID: PMC4549580 DOI: 10.15537/smj.2015.8.12024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) is commonly encountered in daily clinical practice. After diagnosis, its management frequently carries significant challenges to the clinical practitioner. Treatment of VTE with the inappropriate modality and/or in the inappropriate setting may lead to serious complications and have life-threatening consequences. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia, an expert panel led by the Saudi Association for Venous Thrombo-Embolism (a subsidiary of the Saudi Thoracic Society) and the Saudi Scientific Hematology Society with the methodological support of the McMaster University Guideline working group, this clinical practice guideline was produced to assist health care providers in VTE management. Two questions were identified and were related to the inpatient versus outpatient treatment of acute DVT, and the early versus standard discharge from hospital for patients with acute PE. The corresponding recommendations were made following the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.
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Affiliation(s)
- Fahad M Al-Hameed
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Abstract
Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. The treatment of VTE is undergoing tremendous changes with the introduction of the new direct oral anticoagulants and clinicians need to understand new treatment paradigms. This article, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. Well-managed warfarin therapy remains an important anticoagulant option and it is hoped that anticoagulation providers will find the guidance contained in this article increases their ability to achieve optimal outcomes for their patients with VTE Pivotal practical questions pertaining to this topic were developed by consensus of the authors and were derived from evidence-based consensus statements whenever possible. The medical literature was reviewed and summarized using guidance statements that reflect the consensus opinion(s) of all authors and the endorsement of the Anticoagulation Forum’s Board of Directors. In an effort to provide practical and implementable information about VTE and its treatment, guidance statements pertaining to choosing good candidates for warfarin therapy, warfarin initiation, optimizing warfarin control, invasive procedure management, excessive anticoagulation, subtherapeutic anticoagulation, drug interactions, switching between anticoagulants, and care transitions are provided.
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Fernandez MM, Hogue S, Preblick R, Kwong WJ. Review of the cost of venous thromboembolism. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:451-62. [PMID: 26355805 PMCID: PMC4559246 DOI: 10.2147/ceor.s85635] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Venous thromboembolism (VTE) is the second most common medical complication and a cause of excess length of hospital stay. Its incidence and economic burden are expected to increase as the population ages. We reviewed the recent literature to provide updated cost estimates on VTE management. Methods Literature search strategies were performed in PubMed, Embase, Cochrane Collaboration, Health Economic Evaluations Database, EconLit, and International Pharmaceutical Abstracts from 2003–2014. Additional studies were identified through searching bibliographies of related publications. Results Eighteen studies were identified and are summarized in this review; of these, 13 reported data from the USA, four from Europe, and one from Canada. Three main cost estimations were identified: cost per VTE hospitalization or per VTE readmission; cost for VTE management, usually reported annually or during a specific period; and annual all-cause costs in patients with VTE, which included the treatment of complications and comorbidities. Cost estimates per VTE hospitalization were generally similar across the US studies, with a trend toward an increase over time. Cost per pulmonary embolism hospitalization increased from $5,198–$6,928 in 2000 to $8,764 in 2010. Readmission for recurrent VTE was generally more costly than the initial index event admission. Annual health plan payments for services related to VTE also increased from $10,804–$16,644 during the 1998–2004 period to an estimated average of $15,123 for a VTE event from 2008 to 2011. Lower costs for VTE hospitalizations and annualized all-cause costs were estimated in European countries and Canada. Conclusion Costs for VTE treatment are considerable and increasing faster than general inflation for medical care services, with hospitalization costs being the primary cost driver. Readmissions for VTE are generally more costly than the initial VTE admission. Further studies evaluating the economic impact of new treatment options such as the non-vitamin K antagonist oral anticoagulants on VTE treatment are warranted.
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Affiliation(s)
- Maria M Fernandez
- RTI-Health Solutions, Market Access and Outcomes Strategy, Research Triangle Park, NC, USA
| | - Susan Hogue
- RTI-Health Solutions, Market Access and Outcomes Strategy, Research Triangle Park, NC, USA
| | - Ronald Preblick
- Daiichi Sankyo, Inc., Health Economics & Outcomes Research, Parsippany, NJ, USA
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8
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Al-Hameed F, Al-Dorzi HM, Al Momen A, Algahtani F, Al Zahrani H, Al Saleh K, Al Sheef M, Owaidah T, Alhazzani W, Neumann I, Wiercioch W, Brozek J, Schünemann H, Akl EA. Prophylaxis and treatment of venous thromboembolism in patients with cancer: the Saudi clinical practice guideline. Ann Saudi Med 2015; 35:95-106. [PMID: 26336014 PMCID: PMC6074132 DOI: 10.5144/0256-4947.2015.95] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Venous thromboembolism (VTE) is commonly encountered in the daily clinical practice. Cancer is an important VTE risk factor. Proper thromboprophylaxis is key to prevent VTE in patients with cancer, and proper treatment is essential to reduce VTE complications and adverse events associated with the therapy. DESIGN AND SETTINGS As a result of an initiative of the Ministry of Health of Saudi Arabia, an expert panel led by the Saudi Association for Venous Thrombo-Embolism (a subsidiary of the Saudi Thoracic Society) and the Saudi Scientific Hematology Society with the methodological support of the McMaster University working group produced this clinical practice guideline to assist health care providers in evidence-based clinical decision-making for VTE prophylaxis and treatment in patients with cancer. METHODS Six questions related to thromboprophylaxis and antithrombotic therapy were identified and the corresponding recommendations were made following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. RESULTS Question 1. Should heparin versus no heparin be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation? RECOMMENDATION For outpatients with cancer, the Saudi Expert Panel suggests against routine thromboprophylaxis with heparin (weak recommendation; moderate quality evidence).Question 2. Should oral anticoagulation versus no oral anticoagulation be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation? RECOMMENDATION For outpatients with cancer, the Saudi Expert Panel recommends against thromboprophylaxis with oral anticoagulation (strong recommendation; moderate quality evidence).Question 3. Should parenteral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters? RECOMMENDATION For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests thromboprophylaxis with parenteral anticoagulation (weak recommendation; moderate quality evidence).Question 4. Should oral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters? RECOMMENDATION For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests against thromboprophylaxis with oral anticoagulation (weak recommendation; low quality evidence).Question 5. Should low-molecular-weight heparin versus unfractionated heparin be used in patients with cancer being initiated on treatment for venous thromboembolism? RECOMMENDATION In patients with cancer being initiated on treatment for venous thromboembolism, the Saudi Expert Panel suggests low-molecular-weight heparin over intravenous unfractionated heparin (weak; very low quality evidence).Question 6. Should heparin versus oral anticoagulation be used in patients with cancer requiring long-term treatment of VTE? RECOMMENDATION In patients with metastatic cancer requiring long-term treatment of VTE, the Saudi Expert Panel recommends low-molecular-weight heparin (LMWH) over vitamin K antagonists (VKAs) (strong recommendation; moderate quality evidence). In patients with non-metastatic cancer requiring long-term treatment of venous thromboembolism, the Saudi Expert Panel suggests LMWH over VKA (weak recommendation; moderate quality evidence).
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Affiliation(s)
- Fahad Al-Hameed
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Intensive Care Department, King Abdulaziz Medical City, NGHA, Jeddah, Saudi Arabia
| | - Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Intensive Care Department, King Abdulaziz Medical City, NGHA, Riyadh, Saudi Arabia
| | | | - Farjah Algahtani
- Department of Hematology, King Saud University, Riyadh, Saudi Arabia
| | - Hazzaa Al Zahrani
- Department of Hematology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Khalid Al Saleh
- Department of Hematology, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Al Sheef
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Tarek Owaidah
- Department of Hematology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Ignacio Neumann
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Wojtek Wiercioch
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Jan Brozek
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Holger Schünemann
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Elie A. Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Department of Internal Medicine, American University of Beirut, Lebanon
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Misky GJ, Carlson T, Thompson E, Trujillo T, Nordenholz K. Implementation of an acute venous thromboembolism clinical pathway reduces healthcare utilization and mitigates health disparities. J Hosp Med 2014; 9:430-5. [PMID: 24639293 DOI: 10.1002/jhm.2186] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/24/2014] [Accepted: 02/28/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute venous thromboembolism (VTE) is prevalent, expensive, and deadly. Published data at our institution identified significant VTE care variation based on payer source. We developed a VTE clinical pathway to standardize care, decrease hospital utilization, provide education, and mitigate disparities. METHODS Target population for our interdisciplinary pathway was acute medical VTE patients. The intervention included order sets, system-wide education, follow-up phone calls, and coordinated posthospital care. Study data (n = 241) were compared to historical data (n = 234), evaluating outcomes of hospital admission, length of stay (LOS), and reutilization, stratified by payer source. RESULTS A total of 241 patients entered the VTE clinical care pathway: 107 with deep venous thrombosis (44.4%) and 134 with a pulmonary embolism (55.6%). Within the pathway, uninsured VTE patients were admitted at a lower rate than insured patients (65.9 vs 79.1%; P = 0.032). LOS decreased from 4.4 to 3.1 days (P < 0.001) for admitted VTE patients and from 5.9 to 3.1 days among uninsured patients (P = 0.0006). Overall, 30-day emergency department recidivism remained 11%, but declined (17.9% to 13.6%) among uninsured patients (P = 0.593). Fewer pathway patients (5.8%) were readmitted compared to historical patients (9.4%, P = 0.254). Individual cost of care decreased from $7610 to $5295 (P < 0.005) for any VTE patient, and from $9953 to $4304 (P = 0.001) per uninsured patient. CONCLUSIONS Implementing an interdisciplinary, clinical pathway standardized care for VTE patients and dramatically reduced hospital utilization and cost, particularly among uninsured patients. Results of this novel study demonstrate a model for improving transitional care coordination with local community health clinics and delivering care to vulnerable populations. Other disease populations may benefit from the development of a similar model.
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Affiliation(s)
- Gregory J Misky
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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10
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Witt DM, Delate T, Clark NP, Garcia DA, Hylek EM, Ageno W, Dentali F, Crowther MA. Nonadherence with INR monitoring and anticoagulant complications. Thromb Res 2013; 132:e124-30. [PMID: 23800635 DOI: 10.1016/j.thromres.2013.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 05/23/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This study tests the hypothesis that nonadherence with INR monitoring is associated with an increased risk for warfarin-related bleeding and thrombosis and describes patient characteristics associated with INR monitoring nonadherence. MATERIALS AND METHODS This was a retrospective, longitudinal, matched cohort study wherein patients were categorized into adherent and nonadherent cohorts; adherent patients were matched 2:1 to nonadherent patients. The primary study endpoint was the first occurrence of bleeding or thromboembolism. Multivariate logistic regression modeling identified patient characteristics associated with INR monitoring adherence or nonadherence. RESULTS A total of 4995 and 2544 patients contributed 10729 and 5385 patient-years of warfarin therapy in the adherent and nonadherent groups, respectively. The rate of thromboembolic events during follow up was higher in the nonadherent group than in the adherent group (0.95% vs. 0.62% per patient-year, respectively; p=0.019) and nonadherence to INR monitoring was associated with a moderately higher risk of thromboembolism (adjusted Hazard Ratio=1.51; 95% confidence interval=1.04 - 2.20). The difference in bleeding between the two groups was not statistically significant. CONCLUSIONS Repeatedly missing INR tests is an easily identified clinical parameter that is associated with moderately increased risk for thromboembolism in patients taking chronic warfarin therapy. Clinicians should carefully consider the underlying thromboembolic risk and extent of nonadherence when weighing the benefits of continued warfarin therapy for a given patient.
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Affiliation(s)
- Daniel M Witt
- Kaiser Permanente Colorado Clinical Pharmacy Research Team, Aurora, CO; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Denver, CO.
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Barra SNC, Paiva L, Providência R, Fernandes A, Marques AL. A review on state-of-the-art data regarding safe early discharge following admission for pulmonary embolism: what do we know? Clin Cardiol 2013; 36:507-15. [PMID: 23720225 DOI: 10.1002/clc.22144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 04/20/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs. HYPOTHESIS This article reviews the state-of-the-art data regarding recognition of very-low-risk PE patients who are potentially eligible for outpatient treatment, along with the safety, management, and cost-effectiveness of this strategy. We propose an algorithm based on collected data that may be useful/practical for identifying patients truly eligible for early discharge. METHODS Comprehensive review of scientific data collected from the MEDLINE and Cochrane databases. Studies selected based on potential scientific interest. Qualitative information extracted regarding feasibility, safety, and cost-effectiveness of outpatient treatment, postdischarge management, and selection of truly low-risk patients. RESULTS Early discharge of low-risk patients seems feasible, safe, and particularly cost-effective. Several risk scores have been developed and/or tested as prediction tools for the recognition of low-risk individuals: the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva score, the Low-Risk Pulmonary Embolism Decision rule, and the Global Registry of Acute Cardiac Events, among others. PESI is the most well-validated model, offering the safest approach at the current time, especially when combined with additional parameters such as troponin I, N-terminal prohormone of brain natriuretic peptide, and echocardiographic markers of right-ventricular dysfunction. CONCLUSIONS Recognition of truly low-risk patients entitled to early hospital discharge and outpatient treatment is possible with current risk-stratification schemes along with selected prognostic parameters, and it may have a colossal impact on healthcare costs.
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12
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Chandra E, Ahmadi M, Bailey MA, Griffin KJ, Berridge DC, Coughlin PA, Scott DJA. Early re-presentations and the potential role of catheter-directed thrombolysis in patients diagnosed with a lower limb deep vein thrombosis: a single-centre experience. Phlebology 2013; 28:404-8. [DOI: 10.1258/phleb.2012.012078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (DVT) restores venous patency, reduces the risk of the post-thrombotic syndrome and may reduce longer term treatment costs. This study assessed the potential role of CDT in patients with DVT with regard to representation following the index event. Methods A retrospective review of all patients with a positive lower limb DVT scan. Potential suitability of each patient to undergo CDT was based on well-recognized inclusion/exclusion criteria. Results In total, 1689 patients underwent a DVT-specific lower limb venous duplex. A total of 269 were found to have a DVT. Fifty-three of these patients met the inclusion criteria for CDT (only 2 underwent CDT). Fifty-nine of the 269 patients with an index DVT re-presented to our institution with a venous thromboembolism-related clinical event. These patients were significantly younger than those who did not reattend. A higher proportion of patients who represented were deemed suitable for CDT for the index DVT compared with those who did not represent (17/59 versus 36/210; P = 0.04). Conclusion This pragmatic study highlights the fact that significant number of patients return to secondary care with actual/perceived complications following initial diagnosis and treatment of a DVT which may have been amenable to CDT.
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Affiliation(s)
- E Chandra
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
| | - M Ahmadi
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
| | - M A Bailey
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
| | - K J Griffin
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
| | - D C Berridge
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
| | - P A Coughlin
- Department of Vascular Surgery, Addenbrookes Hospital, Cambridge, UK
| | - D J A Scott
- Leeds Vascular Institute, Leeds General Infirmary, Leeds
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Davis KA, Miyares MA, Price-Goodnow VS. Optimizing Transition of Care Through the Facilitation of a Pharmacist-Managed Deep Vein Thrombosis Treatment Program. J Pharm Pract 2012; 26:438-41. [DOI: 10.1177/0897190012465953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A pharmacist-managed deep vein thrombosis (DVT) treatment program was put into operation at Jackson Memorial Hospital in Miami, Florida to provide appropriate transition of care to the outpatient setting for patients diagnosed with DVT. A postgraduate year 1 pharmacy practice resident partnered with a clinical pharmacist to establish and implement the DVT pilot program in the emergency department (ED). Once contacted, the pharmacy resident or the clinical pharmacist communicated with the ED physician and made recommendations regarding appropriate anticoagulation. The pharmacist met with the patient to obtain informed consent and provide counseling regarding the anticoagulants. A timely outpatient appointment at the pharmacy-managed warfarin clinic was arranged for the patient and contact information was exchanged between the patient and the pharmacist. On average, patients enrolled in the DVT program from the ED were released 18.29 hours (±7.06) following the time of arrival. Following release from the hospital, 91% of patients attended their outpatient follow-up appointment at the warfarin clinic. Since the initiation of the DVT program, 1 patient experienced a recurrent DVT and major bleed during their treatment course. Due to successful implementation of this pharmacist-managed DVT program in the ED, the services were subsequently extended to inpatients with DVT.
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Affiliation(s)
- Kyle A. Davis
- Pharmacy Department, Jackson Memorial Hospital, Miami, FL, USA
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Gussoni G, Foglia E, Frasson S, Casartelli L, Campanini M, Bonfanti M, Colombo F, Porazzi E, Ageno W, Vescovo G, Mazzone A. Real-world economic burden of venous thromboembolism and antithrombotic prophylaxis in medical inpatients. Thromb Res 2012; 131:17-23. [PMID: 23141845 DOI: 10.1016/j.thromres.2012.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/10/2012] [Accepted: 10/17/2012] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in medical patients, and the economic burden of this disease is plausibly relevant as well. However, few data from real-world observations are available on this topic. Aim of our study was to assess the costs of VTE management and antithrombotic prophylaxis in patients hospitalized in Internal Medicine (IM) departments. MATERIALS AND METHODS The in-hospital paths of 160 patients with VTE (VTE group) and 160 patients receiving prophylaxis and without VTE (NO-VTE group) were retrospectively evaluated within 26IM units in Italy. The economic analysis was undertaken by applying a process analysis, the initial phase of the more comprehensive Activity Based Costing technique. Accordingly to this approach, only information closely linked to VTE or its prevention was registered. RESULTS The total median costs for VTE management were around four-times higher than those for prophylaxis (€ 1,348.68 vs € 373.03). Human resources were the most important cost-driver (55.5% and 65.7% in the VTE and NO-VTE groups), followed by instrumental (24.6% in VTE and 15.5% in NO-VTE) and haematologic tests (12.6% in VTE patients and 13.3% in controls). In the NO-VTE group the direct costs for prophylaxis accounted for 4.5% of total. CONCLUSIONS The real-world data of this study confirm the economic burden of in-hospital treatment of VTE, and the relatively low costs of thromboprophylaxis. A greater adherence to evidence-based protocols for VTE prevention could probably reduce the current financial burden of VTE on healthcare systems.
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Algahtani F, Aseri ZA, Aldiab A, Aleem A. Hospital versus home treatment of deep vein thrombosis in a tertiary care hospital in Saudi Arabia: Are we ready? Saudi Pharm J 2012; 21:165-8. [PMID: 23960831 DOI: 10.1016/j.jsps.2012.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 05/18/2012] [Indexed: 10/28/2022] Open
Abstract
AIM/BACKGROUND Treatment of DVT with LMWHs has been shown recently to be as effective as UFH with suggested lower costs. This study was conducted to determine and compare the cost of in-patient hospital treatment versus outpatient hospital treatment of patients with DVT. METHOD All adult patients with acute proximal DVT referred to the Emergency Department of King Khalid University Hospital, Riyadh, Saudi Arabia between August 2009 and August 2010 were invited to the study. An economic analysis was performed to compare the cost impact of outpatients versus hospital treatment. RESULTS Sixty-one patients were included in the study, 31 were followed in the outpatient setting and 30 as the control group (inpatients). There were no significant differences in the outcome between the outpatient and inpatient group; three patients (9.7%) in the outpatient group and four patients (13.3%) in the inpatient group had recurrent DVT. Mean nursing cost was $55 for the outpatient group and $215 for the inpatient group, mean laboratory monitoring cost was $638 for outpatient group and $1511 for the inpatient group. Hospital stay and doctor's fees amounted to a mean of $1000 for outpatient treatment and $2387 for inpatient treatment, p < 0.0001. The mean outpatient cost was significantly lower than the inpatient cost ($1750 vs. $4338, p < 0.0001). CONCLUSION Outpatient treatment of patients with DVT using LMWHs is cost-effective with no significant differences in the outcome of patients. OPD treatment of DVT is feasible in Saudi Arabia provided there is enough logistic support from thrombosis clinics and those involved in DVT care.
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Affiliation(s)
- Farjah Algahtani
- Hematology-Oncology Division, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S-e496S. [PMID: 22315268 PMCID: PMC3278049 DOI: 10.1378/chest.11-2301] [Citation(s) in RCA: 2452] [Impact Index Per Article: 204.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This article addresses the treatment of VTE disease. METHODS We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. RESULTS For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). CONCLUSION Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
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Affiliation(s)
- Clive Kearon
- Department of Medicine and Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Medicine, Family Medicine, and Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY.
| | | | - Paolo Prandoni
- Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Henri Bounameaux
- Department of Medical Specialties, University Hospitals of Geneva, Geneva, Switzerland
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael E Nelson
- Department of Medicine, Shawnee Mission Medical Center, Shawnee Mission, KS
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael K Gould
- Department of Medicine and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Mark Crowther
- Department of Medicine, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan R Kahn
- Department of Medicine and Clinical Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Gallagher AM, de Vries F, Plumb JM, Haß B, Clemens A, van Staa TP. Quality of INR control and outcomes following venous thromboembolism. Clin Appl Thromb Hemost 2012; 18:370-8. [PMID: 22275390 DOI: 10.1177/1076029611426139] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The objective of this study was to evaluate the pattern of anticoagulation after venous thromboembolism (VTE) in actual clinical practice. MATERIAL AND METHODS This study used the General Practice Research Database. Individuals aged 18+ years with VTE were matched to 3 controls. RESULTS Of the 46 335 patients with VTE and 138 024 controls, 70.2% of cases and 86.6% of controls had no obvious risk factors. The mortality risk was increased substantially around the time of diagnosis (relative hazard rate [RR] around 21) but remained elevated for a further 4 years (RRs around 1.5-2.0). The mean percentage of time spent within the therapeutic range for international normalized ratio (INR) was 57.0%. The lowest rate of VTE recurrence occurred in patients with ≥70% time spent within therapeutic range (RR of 0.50, 95% CI 0.39-0.63 compared to <30%). CONCLUSIONS Higher time spent within therapeutic INR range was associated with lower risks of VTE recurrence and death due to VTE.
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Affiliation(s)
- Arlene M Gallagher
- General Practice Research Database, Medicines and Healthcare products Regulatory Agency, London, UK
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18
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Health care disparities in the acute management of venous thromboembolism based on insurance status in the U.S. J Thromb Thrombolysis 2011; 32:393-8. [DOI: 10.1007/s11239-011-0632-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
OBJECTIVE Deep vein thrombosis and pulmonary embolism - together referred to as venous thromboembolism (VTE) - result in a major burden on healthcare systems. However, to the authors' knowledge no comprehensive review of the economic burden of VTE has so far been published. METHODS A literature search was carried out to identify references published in English since 1997 using Medline, the Cochrane Library and the Health Economic Evaluations Database. The primary outcomes of interest were 'all-cause' VTE and VTE after major orthopedic surgery. RESULTS A total of 1,037 full research articles and abstracts were screened for inclusion in the review. Of these, ten cost-of-illness studies were identified that met the inclusion criteria and are included in the current review. The results of large US database analyses vary, indicating costs of the initial VTE of approximately US$3,000-9,500. The total costs related to VTE over 3 months (US$5,000), 6 months (US$10,000) and 1 year (US$33,000) were considerable. Studies conducted in the European Union indicate lower additional inpatient costs after VTE of €1,800 after 3 months and €3,200 after 1 year, which still represent a considerable impact on healthcare systems. Complications after VTE can be very expensive, with estimates of the additional cost of treating the post-thrombotic syndrome ranging from $426 to $11,700 and heparin-induced thrombocytopenia from $3,118 to $41,133. A limitation of studies using older data is that recent changes in the treatment of VTE may affect the generalizability of these findings. CONCLUSIONS Complications associated with VTE are frequent and costly. In particular, the cost of complications resulting from prophylaxis and treatment of VTE, such as post-thrombotic syndrome and heparin-induced thrombocytopenia, had a considerable economic impact.
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Modest response in translation to home management of deep venous thrombosis. Am J Med 2010; 123:1107-13. [PMID: 20961524 DOI: 10.1016/j.amjmed.2010.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 07/06/2010] [Accepted: 07/07/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND years may elapse between the publication of results of rigorous randomized trials and changes in clinical practice. It is not often that a definitive time interval can be identified that shows the time taken for published clinical trials to affect clinical practice. In the present study, we track the timelines of evidence for home treatment of deep venous thrombosis and its eventual impact on hospitalizations and early discharge. METHODS the number of patients discharged from short-stay hospitals throughout the United States between 1979 and 2006 with a principal diagnosis of deep venous thrombosis and the proportion discharged in ≤ 2 days was determined from The National Hospital Discharge Survey. We also attempted to identify all published articles that reported home treatment of deep venous thrombosis in unselected populations. RESULTS eleven years after demonstration of the safety and efficacy of home treatment, there was only a 21% decrease in the population-based incidence of hospitalizations of patients with a principal diagnosis of deep venous thrombosis. The proportion of patients with a principal diagnosis of deep venous thrombosis who were discharged in ≤ 2 days began to increase prominently after the 1996 publication of trials showing the safety and efficacy of home treatment, and continued to increase through 2006. However, the proportion discharged early remained modest (21% to 25%). CONCLUSIONS whether the slow implementation of home treatment reflects a cautious approach accompanied by a gradual testing of shortened hospitalization for deep venous thrombosis or other factors is uncertain.
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Fajt M, Petrov A. Clopidogrel Hypersensitivity: A Novel Multi-Day Outpatient Oral Desensitization Regimen. Ann Pharmacother 2010; 44:11-8. [DOI: 10.1345/aph.1m379] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Clopidogrel hypersensitivity has posed a problem for the acute treatment and long-term care of a particular patient population with coronary artery disease and stent placement. Patients with clopidogrel hypersensitivity have had an increased risk of hypersensitivity reactions, including anaphylaxis, if they ingest clopidogrel without undergoing an oral desensitization procedure. The previously published desensitization protocols have either been performed in the intensive care unit, requiring significant cost and healthcare utilization, or have required a full-day outpatient commitment on behalf of the patient. OBJECTIVE To determine whether a multi-day outpatient oral clopidogrel desensitization protocol is effective and safe for patients with clopidogrel hypersensitivity. METHODS gWe retrospectively assessed the efficacy of a 10-dose outpatient multiday clopidogrel desensitization protocol performed in a university allergy-immunology center from April 2006 to October 2008 in patients with clopidogrel hypersensitivity. Patients were desensitized over 2–3 half-day clinical visits and were able to go home between desensitization sessions. A preliminary cost analysis was performed using the average of actual costs for the outpatient clopidogrel desensitization procedure and was compared with the average cost for an inpatient oral desensitization completed at our institution. RESULTS Eight patients with coronary artery disease, cardiac stent placement, and clopidogrel hypersensitivity underwent an outpatient multi-day oral clopidogrel desensitization procedure. All patients were successfully desensitized with the multi-day protocol without complications. No patient had recurrence of allergic reaction 3 months after the procedure. A preliminary cost analysis demonstrated a lower cost for the outpatient compared to the inpatient oral clopidogrel desensitization protocol. CONCLUSIONS This outpatient 10-dose multi-day clopidogrel desensitization protocol is a safe and effective novel approach for the treatment of clopidogrel hypersensitivity in patients with coronary artery disease and cardiac stent placement. In addition to safety and efficacy, this protocol offers the patient the convenience of avoiding hospital admission or full-day time commitments.
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Affiliation(s)
- Merritt Fajt
- Merritt Fajt MD, Fellow in Allergy-Immunology, Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Andrej Petrov
- Andrej Petrov MD, Assistant Professor of Medicine, School of Medicine, University of Pittsburgh; Medical Director, Allergy and Clinical Immunology, Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center; Associate Program Director of Allergy-Immunology Fellowship, School of Medicine, University of Pittsburgh
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The Kaiser Permanente Colorado Clinical Pharmacy Anticoagulation Service as a model of modern anticoagulant care. Thromb Res 2008; 123 Suppl 1:S36-41. [DOI: 10.1016/j.thromres.2008.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW Osteoporosis is the most common serious side effect of long-term unfractionated heparin use. Until recently, it was unknown whether long-term low-molecular-weight heparin was associated with any change in bone mineral density. With increasing long-term low-molecular-weight heparin use, for a variety of indications, this was an important knowledge gap. RECENT FINDINGS We recently completed an a-priori planned substudy to assess the effect of low-molecular-weight heparin on bone mineral density in an ongoing multicenter multinational randomized trial designed to compare the effect of low-molecular-weight heparin prophylaxis on pregnancy outcomes in thrombophilic pregnant women. The results revealed that there is no significant difference in mean bone mineral density between a low-molecular-weight heparin prophylaxis group and a no prophylaxis group. The study was not adequately powered to detect differences in absolute fracture risk. SUMMARY Recent results suggest that the use of long-term prophylactic low-molecular-weight heparin in pregnancy is not associated with a significant decrease in bone mineral density. Whether higher doses might be a risk factor for osteoporosis is still an unanswered question. It is also possible that subgroups are more susceptible. Overall, women should be reassured regarding the risk of osteoporosis associated with the use of prophylactic dose of low-molecular-weight heparin during their pregnancy.
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Clark NP, Witt DM, Delate T, Trapp M, Garcia D, Ageno W, Hylek EM, Crowther MA. Thromboembolic Consequences of Subtherapeutic Anticoagulation in Patients Stabilized on Warfarin Therapy: The Low INR Study. Pharmacotherapy 2008; 28:960-7. [PMID: 18657012 DOI: 10.1592/phco.28.8.960] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente Colorado, 280 Exempla Circle, Lafayette, CO 80026, USA.
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Garcia DA, Witt DM, Hylek E, Wittkowsky AK, Nutescu EA, Jacobson A, Moll S, Merli GJ, Crowther M, Earl L, Becker RC, Oertel L, Jaffer A, Ansell JE. Delivery of Optimized Anticoagulant Therapy: Consensus Statement from the Anticoagulation Forum. Ann Pharmacother 2008; 42:979-88. [PMID: 18559954 DOI: 10.1345/aph.1l098] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To provide recommendations, policies, and procedures pertaining to the provision of optimized anticoagulation therapy designed to achieve desired clinical endpoints while minimizing the risk of anticoagulant-related adverse outcomes (principally bleeding and thrombosis). Study Selection and Data Extraction: Due to this document's scope, the medical literature was searched using a variety of strategies. When possible, recommendations are supported by available evidence; however, because this paper deals with processes and systems of care, high-quality evidence (eg, controlled trials) is unavailable. In these cases, recommendations represent the consensus opinion of all authors who constitute the Board of Directors of The Anticoagulation Forum, an organization dedicated to optimizing anticoagulation care. The Board is composed of physicians, pharmacists, and nurses with demonstrated expertise and significant collective experience in the management of patients receiving anticoagulation therapy. Data Synthesis: Recommendations for delivering optimized anticoagulation therapy were developed collaboratively by the authors and are summarized in 9 key areas: (I) Qualifications of Personnel, (II) Supervision, (III) Care Management and Coordination, (IV) Documentation. (V) Patient Education, (VI) Patient Selection and Assessment, (VII) Laboratory Monitoring, (VIII) Initiation and Stabilization of Warfarin Therapy, and (IX) Maintenance of Therapy. Recommendations are intended to inform the development of care systems containing elements with demonstrated benefit in improvement of anticoagulation therapy outcomes. Recommendations for delivering optimized anticoagulation therapy are intended to apply to all clinicians involved in the care of outpatients receiving anticoagulation therapy, regardless of the structure and setting in which that care is delivered. Conclusions: Anticoagulation therapy, although potentially life-saving, has inherent risks. Whether a patient is managed in a solo practice or a specialized anticoagulation management service, a systematic approach to the key elements outlined herein will reduce the likelihood of adverse events. The need for continued research to validate optimal practices for managing anticoagulation therapy is acknowledged.
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Affiliation(s)
- David A Garcia
- University of New Mexico School of Medicine; Medical Director, Anticoagulation Clinic, University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM
| | - Daniel M Witt
- School of Pharmacy, University of Colorado; Manager, Clinical Pharmacy Services, Kaiser Permanente Colorado, Denver, CO
| | - Elaine Hylek
- School of Medicine, Boston University; Director, Anticoagulation Clinic, Boston Medical Center, Boston, MA
| | - Ann K Wittkowsky
- Clinical Professor, School of Pharmacy, University of Washington; Director, Anticoagulation Services, University of Washington Medical Center, Seattle, WA
| | - Edith A Nutescu
- Clinical Associate Professor of Pharmacy Practice; Director, Antithrombosis Center, College of Pharmacy & Medical Center, The University of Illinois at Chicago, Chicago, IL
| | - Alan Jacobson
- Anticoagulation Services; Associate Chief of Staff for Research, Loma Linda Veterans Affairs Medical Center, Loma Linda, CA
| | - Stephan Moll
- School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Geno J Merli
- Medicine, Jefferson Medical College, Thomas Jefferson University; Senior Vice President and Chief Medical Officer, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Mark Crowther
- Academic Division Director, Hematology and Thromboembolism, McMaster University; Director of Laboratory Hematology, Hamilton Regional Laboratory Medicine Program; Head of Service, Hematology, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Laura Earl
- Practicing Nurse, University of New Mexico, Albuquerque
| | - Richard C Becker
- Medicine, School of Medicine, Duke University; Director, Duke Cardiovascular Thrombosis Center, Duke Clinical Research Institute, Durham, NC
| | - Lynn Oertel
- Clinical Nurse Specialist, Anticoagulation Management Services, Massachusetts General Hospital, Boston, MA
| | - Amir Jaffer
- Division Chief of Hospital Medicine, University of Miami, Miami, FL
| | - Jack E Ansell
- Department of Medicine, Lenox Hill Hospital, New York, NY
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Groce JB. Initial management of deep venous thrombosis in the outpatient setting. Am J Health Syst Pharm 2008; 65:866-74. [PMID: 18436734 DOI: 10.2146/ajhp070408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- James B Groce
- Campbell University School of Pharmacy, Buies Creek, NC, USA.
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Spyropoulos AC. Outpatient-Based Primary and Secondary Thromboprophylaxis With Low-Molecular-Weight Heparin. Clin Appl Thromb Hemost 2008; 14:63-74. [PMID: 17895502 DOI: 10.1177/1076029607304088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Although oral vitamin K antagonists such as warfarin have been the mainstay of thromboprophylaxis in the outpatient setting, warfarin has potential disadvantages, including food and drug interactions, the need for drug monitoring, intolerance, failure, and hypersensitivity syndromes. The use of low-molecular-weight heparin as a primary or secondary thromboprophylactic drug in the outpatient setting for extended prophylaxis or as outpatient bridging therapy has been addressed less extensively. Available evidence shows that low-molecular-weight heparin can be used as extended outpatient-based primary thromboprophylaxis for major orthopedic and cancer surgery and is a safe and effective alternative to warfarin in long-term secondary thromboprophylaxis, especially in cancer patients and in pregnant women. Low-molecular-weight heparin can also be used as an alternative to unfractionated heparin as outpatient-based bridging therapy. In addition to good clinical outcomes and financial benefits, mainly resulting from a reduction in the length of hospital stay, the use of extended-duration low-molecular-weight heparin in the outpatient setting appears to be feasible, with high patient compliance.
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Affiliation(s)
- Alex C Spyropoulos
- Clinical Thrombosis Center, Lovelace Medical Center, Albuquerque, New Mexico 87108, USA.
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Hyers TM, Spyropoulos AC. Community-based treatment of venous thromboembolism with a low-molecular-weight heparin and warfarin. J Thromb Thrombolysis 2007; 24:225-32. [PMID: 17334932 DOI: 10.1007/s11239-007-0020-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Accepted: 02/07/2007] [Indexed: 10/23/2022]
Abstract
This multicenter, prospective, open label, observational study evaluated practice patterns of physicians using tinzaparin, a low-molecular-weight heparin (LMWH), and warfarin for the treatment of deep venous thrombosis (DVT) with or without pulmonary embolism (PE). Short-term recurrence of venous thromboembolism (VTE) and safety were also evaluated. Patients with an objective diagnosis of DVT, with or without PE, were invited by their physician to participate in this study. Treatment was given according to the approved U.S. package inserts for tinzaparin (175 IU/kg SQ QD) and warfarin and the clinical judgment of the prescribing physician. Baseline patient history including demographic information and the results of tests to confirm the diagnosis of DVT, with or without PE, were collected. Follow-up information included the treatment setting in which each dose of tinzaparin was administered, medical training of the person administering tinzaparin doses, timing of initiation of warfarin with respect to that of tinzaparin, length of overlap of tinzaparin and warfarin therapy, and adverse experiences. A total of 334 patients were enrolled at 65 sites. Patients across a wide age (range 18-93 years old) and body weight (range 40-261 kg) were included. Overall, 27.3% of patients had cancer, and 50% of the overall study population reported more than one VTE risk factor. Mean duration of tinzaparin treatment was 7.61 days. Therapy at home was more common in suburban and rural settings than in urban settings. High proportions of patient, even among the small group with concurrent PE, were treated at home with self-injection. Severity of disease was the primary reason for hospitalization. Home treatment of DVT, with or without PE, with self administration of tinzaparin at 175 IU SQ once-daily was safe and resulted in an acceptably low rate of recurrent venous thromboembolism and adverse events. Home therapy in the usual practice setting should achieve substantial overall cost savings in the treatment of DVT.
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Affiliation(s)
- Thomas M Hyers
- Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO, USA.
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29
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Carter BL. Hypertension Disease Management Services. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Saseen JJ, Grady SE, Hansen LB, Hodges BM, Kovacs SJ, Martinez LD, Murphy JE, Page RL, Reichert MG, Stringer KA, Taylor CT. Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists. Pharmacotherapy 2006; 26:1816-25. [PMID: 17125444 DOI: 10.1592/phco.26.12.1816] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Joseph J Saseen
- American College of Clinical Pharmacy, Kansas City, MO 64111, USA.
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Le Gall C, Jacques E, Medjebeur C, Darques L, Briand F, Haddad J, Bleichner G. Low molecular weight heparin self-injection training: assessment of feasibility, tolerance and economic analysis in emergency departments. Eur J Emerg Med 2006; 13:264-9. [PMID: 16969230 DOI: 10.1097/00063110-200610000-00004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to assess low molecular weight heparin auto-injection skills of self-supporting patients, taught by a nurse through a rapid demonstration in an emergency department. METHODS The study was a prospective, multicentre study, carried out in emergency departments. It included all ambulatory attending patients over 18 years of age, who were given a lower limb cast in an emergency ward and provided with limited orthopaedic treatment. Eligible patients who accepted self-injection training were given a quick demonstration by the nurse in the emergency ward. A questionnaire about the perception of the patient was completed at the beginning of the treatment and at the end of the treatment. A surveillance chart for recording injections and side effects was also given to the patient, and platelet counts were performed twice weekly. FINDINGS Two hundred and fourteen patients have been assessed. Forty-four patients (20.5%) were judged inappropriate for training (n=19) or refused it (n=25). Primary perception of the self-injection method showed absence of fear of injections among patients in 43.7% of cases. Training was successful in 88% of cases. Twenty-one patients out of 170 (12%) gave up after completing the training. Questionnaires given at the end of the treatment found a generally favourable opinion on self-injections among 73.26% of patients (n=86). Compliance was good - 95.5% of patients completed all their injections. Platelet counts were considered appropriate only in 52.5% of cases. INTERPRETATION It seems possible to extend the practice of self-injection to other types of injections prescribed after discharge from the emergency department, such as preventive low molecular weight heparin for surgical or medical purposes and curative ambulatory low molecular weight heparin treatment for deep vein thrombosis.
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Kuntz JG, Cheesman JD, Powers RD. Acute thrombotic disorders. Am J Emerg Med 2006; 24:460-7. [PMID: 16787806 DOI: 10.1016/j.ajem.2006.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 01/14/2006] [Indexed: 10/24/2022] Open
Abstract
The acquired hypercoagulable states are responsible for a broad range of thrombotic and thromboembolic disorders. Symptoms and signs of acute ischemia or organ dysfunction will lead many of these patients to seek care in EDs. Proper diagnosis and therapy must be based on an understanding of epidemiology and pathophysiology. Immediate anticoagulation with heparin may not always be the treatment of choice; careful analysis of clinical and laboratory parameters is necessary to arrive at the safest and most effective course of action. Newer anticoagulants, including low-molecular-weight heparins and nonheparin compounds, are changing the therapeutic approach to many of these disorders.
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Affiliation(s)
- Joanne G Kuntz
- Division of Emergency Medicine, University of Connecticut School of Medicine, Famington, CT 06030, USA
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Abstract
Anticoagulants are used for the prevention and treatment of venous thromboembolism and for the secondary prevention of stroke and myocardial infarction. The list of available anticoagulants includes unfractionated heparin, low molecular weight heparins, fondaparinux, warfarin and the direct thrombin inhibitors. Numerous randomised controlled trials have pitted one anticoagulant against another to ascertain superiority in terms of safety and efficacy. Differences in these outcomes are assessed using appropriate statistical tests. When a statistically significant difference is found, it is generally accepted that one option is superior to another. There is also an interest in whether there is a clinically significant difference between two or more treatments, even when there may not be a statistically significant difference. This decision is reached through clinical judgment based on logical and ethical considerations. Another important way to judge the difference between alternative treatment strategies is to test for economically significant differences. This is accomplished through pharmacoeconomic analysis. This paper reviews the evidence gathered from published studies designed to detect an economically significant difference between two or more anticoagulants used for the same clinical indication.
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Affiliation(s)
- David Hawkins
- South University School of Pharmacy, Savannah, GA 31406, USA.
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Santamaría A, Juárez S, Reche A, Gómez-Outes A, Martínez-González J, Fontcuberta J. Low-molecular-weight heparin, bemiparin, in the outpatient treatment and secondary prophylaxis of venous thromboembolism in standard clinical practice: the ESFERA Study. Int J Clin Pract 2006; 60:518-25. [PMID: 16700847 DOI: 10.1111/j.1368-5031.2006.00947.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study is to assess the clinical and economic outcomes associated with outpatient treatment and secondary prophylaxis of acute venous thromboembolism (VTE) with a low-molecular-weight heparin, bemiparin. This study was designed as an open-label, multicentre, prospective, cohort study in standard clinical practice. Sixty-three investigators from 54 Spanish centres participated in the study. Five hundred eighty-three patients (434 outpatients and 149 inpatients) with acute VTE were followed up for 98 days (median). Outcome measures were costs and adverse events during initial VTE treatment with bemiparin (outpatient vs. inpatient cohorts) and long-term treatment [bemiparin (BEM) vs. vitamin K antagonists (VKA) cohorts]. Mean total costs per patient were lower in the outpatient cohort as compared with those in the inpatient cohort (1206 vs. 5191 euros; difference = -3985 euros; p < 0.001), with similar rates of adverse events (5.1 outpatient vs. 7.4% inpatient; p = 0.196) over 98 days. Mean total costs per patient were similar in the BEM/BEM and BEM/VKA cohorts (3616 vs. 3831 euros; difference = -215 euros; p = 0.412), but patients on long-term bemiparin treatment had lower rates of major bleeding (0.4 vs. 1.7%; p = 0.047), minor bleeding (1.8 vs. 6%; p = 0.032) and total adverse events (2.9 vs. 9.5%; p = 0.007) than patients in the BEM/VKA cohort. Outpatient management of VTE with bemiparin in selected patients resulted in significant cost-savings compared to inpatient treatment, while maintaining effectiveness and safety. Bemiparin may be a safer and cost-neutral alternative to VKA for long-term treatment of VTE.
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Affiliation(s)
- A Santamaría
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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Helling DK, Nelson KM, Ramirez JE, Humphries TL. Kaiser Permanente Colorado Region Pharmacy Department: Innovative Leader in Pharmacy Practice. J Am Pharm Assoc (2003) 2006; 46:67-76. [PMID: 16529342 DOI: 10.1331/154434506775268580] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe innovative programs within the Kaiser Permanente Pharmacy Department in the Colorado Region. SETTING One of eight regions of the nation's largest nonprofit health maintenance organization. PRACTICE DESCRIPTION The pharmacy department comprises two services, Clinical Pharmacy Services and Pharmacy Operations/Support Services, which are integrated to provide comprehensive care. PRACTICE INNOVATION Within Clinical Pharmacy Services, the Primary Care Clinical Pharmacy Services team works alongside physicians to provide integrated patient care. The Centralized Clinical Pharmacy Service teams manage large groups of patients effectively and efficiently. The Clinical Pharmacy Specialty staff and the Disease State Management clinical pharmacy specialists provide focused drug therapy expertise. MAIN OUTCOME MEASURES Clinical and economic outcomes; recognition by national organizations. RESULTS Technological innovations are used within Pharmacy Operations/Support Services to increase pharmacists' time for patient care activities. The use of technology by the Pharmacy Automated Refill Center and the implementation of ScriptPro in the medical office pharmacies decrease dispensing demands by processing large volumes of prescriptions. Workflow in the medical office pharmacies has also been reengineered to increase efficiency. Various programs have been developed by the Pharmacy Information Technology Service to support patient care initiatives. Benchmark clinical and economic outcomes have been demonstrated. Positive outcomes have also resulted in quality and safety awards and captured the attention of national pharmacy and medical organizations. CONCLUSION The Colorado Region Pharmacy Department has been recognized as a leader in pharmacy practice through the development of innovative services that provide exceptional patient care.
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Affiliation(s)
- Dennis K Helling
- Department of Pharmacy, Kaiser Permanente Colorado Region, Aurora 80011-9045, USA.
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Abstract
Intravenous (IV) infusion of unfractionated heparin (UFH) followed by oral administration of warfarin remains the cornerstone of clinical treatment of deep vein thrombosis (DVT). Results from numerous clinical trials demonstrate that subcutaneously administered low-molecular-weight heparin (LMWH) is at least as effective and as safe as IV UFH. Treatment with LMWH has several clinical advantages over treatment with UFH, including less-frequent dosing and elimination of the need for monitoring. The introduction of LMWHs has made it possible for physicians to offer outpatient treatment of DVT, with the associated advantage of reduced costs due to shortened hospital stays. However, the optimal duration of anticoagulant therapy after DVT is still debated, as it depends on an individual patient's potential risk for recurrence or treatment-associated complications. Patients are usually risk stratified on the basis of multiple clinical characteristics, including the location of thromboemboli, the presence or absence of cancer, the assumed etiology or cause of DVT (idiopathic vs. due to a transient risk factor), and the presence of certain thrombophilic conditions. High-risk patients often receive inpatient treatment with UFH or LMWH and are candidates for long-term (> or = 6 months) oral anticoagulation, whereas short-term anticoagulation (3 to 6 months) is usually indicated for patients who are at lower risk of recurrence or therapeutic complications and who can be treated with LMWH on an outpatient basis. The introduction of LMWHs has resulted in significant clinical progress for the treatment of DVT.
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Affiliation(s)
- Geno Merli
- Jefferson Antithrombotic Therapy Service, Division of Internal Medicine, Thomas Jefferson University Hospital, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Crowther M, McCourt K. Venous thromboembolism: a guide to prevention and treatment. Nurse Pract 2005; 30:26-9, 32-4, 39-43; quiz 44-5. [PMID: 16094200 DOI: 10.1097/00006205-200508000-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Maryanne Crowther
- Heart Failure Center, Jersey Shore University Medical Center, Neptune, NJ, USA
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Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest 2005; 127:1515-22. [PMID: 15888822 DOI: 10.1378/chest.127.5.1515] [Citation(s) in RCA: 258] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
CONTEXT A growing body of reports has documented the ability of anticoagulation management services to help patients receiving warfarin therapy achieve better outcomes compared to the care provided by their personal physicians (ie, usual care). OBJECTIVE To compare clinical outcomes associated with anticoagulation therapy provided by a clinical pharmacy anticoagulation service (CPAS) to usual care. DESIGN Retrospective, observational cohort study, 6 months in duration. SETTING Large nonprofit, group-model health maintenance organization. PATIENTS A total of 6,645 patients receiving warfarin therapy were included in the final analyses (intervention group, 3,323 patients; control group, 3,322 patients). INTERVENTION Anticoagulation therapy for patients in the intervention group was managed by a centralized, telephonic CPAS. Therapy for patients in the control group was managed in the usual manner by their personal physicians. MAIN OUTCOME MEASURES The primary outcome was the occurrence of anticoagulation therapy-related complications. A secondary outcome was the proportion of time spent in the target international normalized ratio (INR) range for each patient. Cox proportional hazards regression analyses were used to examine the risk of complications in relation to the study group. RESULTS Patients in the CPAS were 39% less likely to experience an anticoagulation therapy-related complication than were patients in the control group (hazard ratio, 0.61; 95% confidence interval, 0.42 to 0.88). The number of patients needed to treat to prevent an anticoagulation therapy complication was 52. Additional analyses revealed that improved outcomes associated with CPAS were mediated largely through improved therapeutic INR control. Patients in the CPAS group spent 63.5% of study period days within their target INR range compared to 55.2% in the control group (p < 0.001). CONCLUSIONS A centralized, telephonic, pharmacist-managed anticoagulation monitoring service reduced the risk of anticoagulation therapy-related complications compared to that with usual care. The cumulative evidence supporting the superior care associated with implementing a pharmacist-managed anticoagulation monitoring service was sufficient to recommend widespread implementation.
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Willey VJ, Bullano MF, Hauch O, Reynolds M, Wygant G, Hoffman L, Mayzell G, Spyropoulos AC. Management patterns and outcomes of patients with venous thromboembolism in the usual community practice setting. Clin Ther 2004; 26:1149-59. [PMID: 15336480 DOI: 10.1016/s0149-2918(04)90187-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objectives of this study were to observe a commercially insured sample diagnosed with a venous thromboembolism (VTE) event and treated postevent with warfarin and to detail the thromboembolic and bleeding outcomes in the time periods during warfarin therapy and after discontinuation of such therapy. METHODS This retrospective, observational cohort study used medical, pharmacy, and eligibility data from 2 US health plans. Study inclusion required an inpatient diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE) between January 1, 1998, and December 31, 2000; warfarin, heparin, or low-molecular-weight heparin within 30 days after diagnosis; no VTE diagnosis; and no anticoagulant use for 3 months preceding diagnosis. A random sample of medical charts was abstracted to validate VTE events and collect prothrombin time/international normalized ratio (INR) result data. Recurrent VTE events, bleeding events, and proportion of time within INR range were captured in the postindex VTE event time period. Univariate and multivariate statistical techniques were used to assess outcomes. RESULTS A total of 2,090 patients were identified with a newly diagnosed VTE event (DVT only, 1450; PE with or without DVT, 640). Mean (SD) age was 61.7 (16) years; mean (SD) follow-up time after the index diagnosis was 21.3 (10) months. Overall mean (SD) length of warfarin therapy was 6.6 (6) months. During the follow-up period, 224 patients (10.7%) experienced a recurrent VTE event and 122 patients (5.8%) experienced a bleeding event requiring hospitalization. The cumulative incidence of recurrent VTE events over 3 and 6 months was 9.0% and 10.9%, respectively. Using the chart abstraction subset, patients were within the appropriate INR range 37.7% of the time while receiving warfarin. CONCLUSIONS Negative outcomes associated with warfarin therapy-recurrent VTE events and bleeding requiring hospitalization-were experienced by 10.7% and 5.8% of patients, respectively. These data suggest that negative outcomes may be more prevalent in usual community medical practice compared with rates observed in the controlled environment of the clinical trial or specialized anticoagulation clinic.
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Sprague S, Cook DJ, Anderson D, O'Brien BJ. A systematic review of economic analyses of low-molecular-weight heparin for the treatment of venous thromboembolism. Thromb Res 2004; 112:193-201. [PMID: 14987911 DOI: 10.1016/j.thromres.2003.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2003] [Revised: 11/28/2003] [Accepted: 12/01/2003] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Public concerns about the increase in health care expenditure have prompted investigators to analyze the costs and benefits of health care interventions. We conducted a systematic review of economic analyses of venous thromboembolism treatment focusing on studies evaluating low-molecular-weight heparin. MATERIALS AND METHODS We identified studies by a MEDLINE search and a review of bibliographies of retrieved articles. From each eligible study, we extracted data on the study characteristics, the effectiveness, and the cost of managing the venous thromboembolism with respect to treatment. We critically appraised the studies according to the framework from the Users' Guides to the Medical Literature XIII: How to Use an Article on Economic Analysis of Clinical Practice. RESULTS Six of these eight economic analyses of venous thromboembolism treatment that met the inclusion criteria for this review showed that low-molecular-weight heparin is associated with less recurrent venous thromboembolism and is less costly than treatment with unfractionated heparin. Although discrete recurrent venous thromboembolism event rates were not included in the seventh study, these investigators concluded that the cost of low-molecular-weight heparin for the treatment of venous thromboembolism treatment was offset by the savings associated with fewer hospital admissions when low-molecular-weight heparin was used. In the eighth study, although the cost of treatment with low-molecular-weight heparin was higher than treatment with unfractionated heparin, the investigators concluded that low-molecular-weight heparin is cost-effective for inpatient management. CONCLUSIONS Low-molecular-weight heparin treatment may confer economic advantages over unfractionated heparin therapy because it does not require anticoagulant monitoring and it facilitates outpatient therapy.
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Affiliation(s)
- Sheila Sprague
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8N 3Z5
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Rodger MA, Gagné-Rodger C, Howley HE, Carrier M, Coyle D, Wells PS. The outpatient treatment of deep vein thrombosis delivers cost savings to patients and their families, compared to inpatient therapy. Thromb Res 2004; 112:13-8. [PMID: 15013267 DOI: 10.1016/j.thromres.2003.09.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2003] [Accepted: 09/29/2003] [Indexed: 11/29/2022]
Abstract
BACKGROUND The outpatient treatment of deep vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) has been shown to be cost-effective from the perspective of a third party payer. The aim of this study is to determine if some or all of these cost savings to third party payers are shifted to patients and their families. METHODS A prospective cohort study with micro-costing of patient/family costs was conducted at the thrombosis units of The Ottawa Hospital. Costs were determined by administering a questionnaire at the end of the patients' heparin therapy. Over a period of 4 months, consecutive patients presenting at the thrombosis units were approached at the initiation of their heparin therapy; 44 patients consented to participate and completed questionnaires were obtained for 41. RESULTS The mean patient/family costs associated with outpatient therapy were significantly less than those associated with inpatient therapy (219.42 dollars versus 402.93 dollars, p=0.003); a savings of 190.91 dollars per patient. Even when lost income to patients/families was ignored, mean patient/family costs remained significantly less for outpatient therapy (72.00 dollars versus 134.29 dollars, p=0.004); a savings of 62.30 dollars per patient. Furthermore, patients preferred outpatient to inpatient therapy by almost 3:1 (30 versus 11, respectively). INTERPRETATION The outpatient treatment of DVT does not result in any net shifting of costs to patients and their families, and further, brings about cost savings. Given the cost savings associated with and the preference of patients for outpatient care, this study further supports the shift of DVT therapy from the inpatient unit to the outpatient clinic.
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Spyropoulos AC, Frost FJ, Hurley JS, Roberts M. Costs and Clinical Outcomes Associated With Low-Molecular-Weight Heparin vs Unfractionated Heparin for Perioperative Bridging in Patients Receiving Long-term Oral Anticoagulant Therapy. Chest 2004; 125:1642-50. [PMID: 15136371 DOI: 10.1378/chest.125.5.1642] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES There have been no health-care cost evaluations comparing the use of low-molecular-weight heparin (LMWH) to unfractionated heparin (UH) as "bridge therapy" in the perioperative period in patients receiving long-term oral anticoagulant (OAC) therapy who need interruption of therapy to undergo an elective surgical procedure. We performed a retrospective analysis of the medical and administrative records of health plan members in a managed care organization who underwent bridge therapy perioperatively with either i.v. UH, administered in a hospital setting, or LMWH, administered primarily in the outpatient setting using disease management guidelines. DESIGN A retrospective analysis of medical and administrative records of treated health plan members meeting inclusion/exclusion criteria during the two study periods (ie, from 1994 to 1996 and from 1998 to 2000). SETTING Staff-model health maintenance organization serving New Mexico. PATIENTS The UH group included persons receiving long-term warfarin therapy from 1994 to 1996 (26 patients), and the LMWH group included persons receiving long-term warfarin therapy from 1998 to 2000 (40 patients) with perioperative use of heparin (either UH or LMWH) as bridge therapy for an elective surgical procedure. INTERVENTIONS Costs were calculated for the period from 10 days before the procedure through 30 days after the procedure. The rates of adverse events (ie, valvular or mural thrombus, intracranial event, transient ischemic attack, peripheral arterial event, venous thromboembolic event, major and minor bleeding, thrombocytopenia, and death) occurring 1 to 30 days postprocedure were determined. MEASUREMENTS AND RESULTS The groups were similar in age, sex, Charlson score, indication for long-term warfarin therapy (ie, arterial/cardiac vs venous), mean international normalized ratio prior to procedure, procedure duration, use of intraprocedural anticoagulant agents or thrombolytic agents, and use of general anesthesia during the procedure (all p > 0.05). A total of 34.6% of UH patients and 40.0% of LMWH patients experienced one or more clinical adverse events within 30 days of the postoperative period, a difference that was not statistically significant (p = 0.67). The mean total health-care costs were 31,625 dollars in the UH group and 18,511 dollars in the LMWH group (p < 0.01). The mean inpatient costs were 28,515 dollars in the UH group and 14,330 dollars in the LMWH group (p < 0.01). Outpatient surgery costs (1,159 dollars vs 53 dollars, respectively; p = 0.01) and pharmacy costs (639 dollars vs 133 dollars, respectively; p < 0.01) were higher in the LMWH group. CONCLUSIONS The mean total health-care costs in the perioperative period were significantly lower (by 13,114 dollars) in patients receiving long-term OAC therapy using LMWH compared to those receiving it using UH for an elective surgical procedure. The cost savings associated with LMWH use were accomplished through the avoidance or minimization of inpatient stays and no increase in the overall rate of clinical adverse events in the postoperative period.
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Affiliation(s)
- Alex C Spyropoulos
- Clinical Thrombosis Center, Lovelace Health Systems, Albuquerque, NM 87108, USA.
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Léger P, Barcat D, Boccalon C, Guilloux J, Boccalon H. Thromboses veineuses des membres inférieurs et de la veine cave inférieure. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.emcaa.2003.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dunn A, Bioh D, Beran M, Capasso M, Siu A. Effect of intravenous heparin administration on duration of hospitalization. Mayo Clin Proc 2004; 79:159-63. [PMID: 14959908 DOI: 10.4065/79.2.159] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine how frequently hospital discharge is delayed to administer intravenous heparin to patients with diverse indications for oral anticoagulation (OAC) medications and how often these delays are potentially avoidable, as assessed by the prevalence of contraindications to outpatient use of low-molecular-weight heparin (LMWH). PATIENTS AND METHODS Records were reviewed from a random sample of 309 patients who received at least 1 dose of OAC medication while hospitalized at the Mount Sinai Hospital in New York City between January 1 and December 31, 1997. Medical records were abstracted to determine admission diagnoses; patient demographics and comorbid conditions; indications for anticoagulation; laboratory data; and treatment and discharge medications, including whether LMWH was prescribed. A delay was defined as the continuation of hospitalization solely to administer intravenous heparin. Predefined criteria were used to classify the delay of discharge as appropriate or avoidable on the basis of the patient's potential eligibility for outpatient treatment with LMWH. RESULTS Discharge was delayed for 75 of 309 patients (24%; 95% confidence interval [CI], 19%-29%); during analysis of the avoidability of delay, 67 of the 75 medical records were available and showed that 32 of 67 delays (48%; 95% CI, 35%-60%) were avoidable. Of patients taking long-term OAC medications who were admitted for reasons unrelated to thromboembolism or bleeding, discharge was delayed for 18 of 146 (12%; 95% CI, 7%-19%); during analysis of the avoidability of delay, 16 of the 18 medical records were available and showed that 9 of 16 delays (56%; 95% CI, 30%-80%) were avoidable. Of patients admitted for acute venous thromboembolism who were not taking long-term OAC medications, discharge was delayed for 24 of 38 (63%; 95% CI, 46%-78%); during analysis of the avoidability of delay, 22 of the 24 medical records were available and showed that 11 of 22 delays (50%; 95% CI, 28%-72%) were avoidable. CONCLUSIONS For patients taking OAC medications, hospital discharge is frequently delayed so that intravenous heparin can be administered; approximately half of these delays could be avoided by outpatient use of LMWH. Studies of the safety, efficacy, and feasibility of outpatient use of LMWH for indications other than deep venous thrombosis are needed because timely discharge of these patients could substantially decrease health care costs.
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Affiliation(s)
- Andrew Dunn
- Division of General Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Segal JB, Bolger DT, Jenckes MW, Krishnan JA, Streiff MB, Eng J, Tamariz LJ, Bass EB. Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: a review of efficacy, safety, and costs. Am J Med 2003; 115:298-308. [PMID: 12967695 DOI: 10.1016/s0002-9343(03)00326-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To summarize the evidence comparing the efficacy, safety, and costs of outpatient and inpatient treatment of venous thromboembolism. METHODS We searched the literature through March 2002 for studies comparing outpatient and inpatient treatment of venous thromboembolism with low molecular weight heparin or unfractionated heparin, and for studies addressing the costs of low molecular weight heparin use in any setting. We included studies with comparison groups or decision analyses. RESULTS Eight studies (three randomized trials and five cohort studies) compared outpatient use of low molecular weight heparin with inpatient use of unfractionated heparin in 3762 patients. The incidence of recurrent deep venous thrombosis was similar in the two groups (median, 4% [range, 0% to 7%] vs. 6% [range, 0% to 9%]), as was major bleeding (median, 0.5% [range, 0% to 2%] vs. 1% [range, 0% to 2%]). Use of low molecular weight heparin was associated with shorter hospitalization (median, 2.7 days [range, 0.03 to 5.1 days] vs. 6.5 days [range, 4 to 9.6 days]) and lower costs (median difference, 1600 dollars). Comparisons of outpatient and in-hospital use of low molecular weight heparin reported no difference in outcomes, but there were savings in hospitalization costs. Low molecular weight heparin was also found to be more cost saving and cost-effective than unfractionated heparin, with savings of 0% to 64% (median, 57%). CONCLUSION The evidence indicates that outpatient treatment of deep venous thrombosis with low molecular weight heparin is likely to be efficacious, safe, and cost-effective.
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Affiliation(s)
- Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Abstract
Once- or twice-daily subcutaneous dosing of LMWHs without laboratory monitoring has facilitated outpatient VTE therapy. Clinical trials have demonstrated at least equivalent efficacy and safety and potential cost savings of outpatient therapy for uncomplicated proximal DVT with LMWH when compared with inpatient therapy. Explicit criteria exist for outpatient DVT therapy. Home therapy for PE requires further evaluation before it can be recommended outside of a trial or other supervised setting.
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Affiliation(s)
- Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Division of General Medical Sciences, Washington University School of Medicine, Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Boucher M, Rodger M, Johnson JA, Tierney M. Shifting from inpatient to outpatient treatment of deep vein thrombosis in a tertiary care center: a cost-minimization analysis. Pharmacotherapy 2003; 23:301-9. [PMID: 12627927 DOI: 10.1592/phco.23.3.301.32102] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To compare the cost of contemporary outpatient and historical inpatient management of proximal lower limb deep vein thrombosis (DVT) in adults. DESIGN Prospective, observational study with historical inpatient cases as controls. SETTING Ambulatory thrombosis clinic of a tertiary care teaching center in Canada. PATIENTS Forty-nine inpatients with DVT from a previous study in 1996 at the same institution who would have been eligible for outpatient therapy if this option had been available, and 51 consecutive patients referred to the ambulatory thrombosis clinic for treatment of DVT between March 2000 and January 2001. INTERVENTION The 49 inpatients received unfractionated heparin, and the 51 outpatients received low-molecular-weight heparin (LMWH). MEASUREMENTS AND MAIN RESULTS A cost-minimization analysis restricted to the hospital perspective was conducted. This design was justified based on the clinical equivalence of the two treatment strategies. All direct hospital costs for treating the 51 consecutive outpatients with LMWH were measured. These data were compared with the cost of treating the inpatients with unfractionated heparin. The analysis horizon was limited to 7 days, based on the duration of hospitalization and length of heparin therapy for DVT before conversion to oral warfarin. The mean cost (in Canadian dollars) per outpatient case was 248 Canadian dollars (95% confidence interval 216-280 Canadian dollars) and was significantly different from the mean cost/inpatient case of 2826 Canadian dollars (adjusted for the difference in fiscal years) (p<0.0005). A breakdown of the outpatient cost showed that nursing time contributed to 51% of the cost, monitoring laboratory tests 5%, drugs 2%, and other costs (diagnostic laboratory tests and medical imaging) 42%. CONCLUSION Converting from inpatient to outpatient treatment of proximal DVT was associated with a significant cost savings for our institution. Accordingly, it is financially advantageous for hospitals to offer this service as it reduces direct costs and does not appear to compromise patient care.
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Affiliation(s)
- Michel Boucher
- Department of Pharmacy, Ottawa Hospital, Ontario, Canada
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Bernardi E, Prandoni P. Safety of low molecular weight heparins in the treatment of venous thromboembolism. Expert Opin Drug Saf 2003; 2:87-94. [PMID: 12904127 DOI: 10.1517/14740338.2.1.87] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low molecular weight heparins (LMWHs) are commonly employed as a substitute for unfractionated heparin (UFH) in the treatment of venous thromboembolic events. Despite their higher cost, the preferential use of LMWHs seemed justified initially as, based on the results of earlier meta-analyses, these compounds were deemed to be more effective and safer than UFH. Although, in this respect, their purported superiority over UFH could not be confirmed by subsequent large, randomised trials and updated meta-analyses, other peculiar features of LMWHs were highlighted, favouring their preferential utilisation in patients with venous thromboembolism. Among these, the possibility of once-daily administration on an out-patient basis, the lower incidence of Type II heparin-induced thrombocytopenia and the lower likelihood of osteoporosis after prolonged treatment periods, appear to be especially prominent. This review attempts to evaluate the available evidence focusing on the safety of LMWHs for the treatment of venous thromboembolism and the current therapeutic options and potential advantages of LMWHs, either in general or in selected patient populations.
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Affiliation(s)
- Enrico Bernardi
- Pronto Soccorso, Azienda Ospedaliera di Padova, Via Giustiniani, n.1, 35128 - Padova, Italy.
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Spyropoulos AC, Hurley JS, Ciesla GN, de Lissovoy G. Management of acute proximal deep vein thrombosis: pharmacoeconomic evaluation of outpatient treatment with enoxaparin vs inpatient treatment with unfractionated heparin. Chest 2002; 122:108-14. [PMID: 12114345 DOI: 10.1378/chest.122.1.108] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES A landmark Canadian randomized controlled clinical trial compared treatment of acute proximal vein thrombosis via low-molecular-weight heparin (LMWH) [enoxaparin] administered primarily at home with IV unfractionated heparin (UH) in the hospital. Results demonstrated equivalent safety and efficacy for home care with enoxaparin with a reduction in cost. Our objective was to validate these findings in the routine practice setting of a US health maintenance organization. DESIGN Retrospective analysis of medical and administrative records of health-plan members meeting inclusion-exclusion criteria of the Canadian trial during the period from 1995 to 1998. SETTING Staff-model health maintenance organization serving New Mexico. PATIENTS Persons presenting as outpatients from 1995 to 1996 or from 1997 to 1998 with acute, proximal deep vein thrombosis (DVT) diagnosed by duplex ultrasonography. INTERVENTIONS Initial anticoagulant therapy of IV UH administered in the hospital (from 1995 to 1996 group, n = 64) or subcutaneous LMWH (enoxaparin) administered primarily at home (from 1997 to 1998 group, n = 65), followed by warfarin therapy. RESULTS No statistically significant differences were observed in the number of recurrent venous thromboembolic events (p = 0.36) or bleeding events (p = 1.0). Mean +/- SD cost per patient was 9,347 dollars +/- 8,469 in the enoxaparin group compared with 11,930 dollars +/- 10,892 in the UH group, a difference of - 2,583 dollars (95% bootstrap-adjusted asymmetrical confidence interval, - 6,147 dollars, + 650 dollars). CONCLUSIONS Retrospective replication of the Canadian study in a US routine (managed) care setting found similar clinical and economic outcomes. Treatment of acute proximal DVT with enoxaparin in a primarily outpatient setting can be accomplished safely and yields savings through avoidance or minimization of inpatient stays.
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Affiliation(s)
- Alex C Spyropoulos
- Clinical Thrombosis Center, Lovelace Health Systems, Albuquerque, NM 87108, USA.
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