Trends of Inpatient Venous Thromboembolism in United States Before and After the Surgeon General's Call to Action

Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade

BACKGROUND

The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution.

METHODS

We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events.

RESULTS

In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022.

CONCLUSIONS

Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

High systemic inflammation response index level is associated with an increased risk of lower extremity deep venous thrombosis: a large retrospective study

BACKGROUND

The association between inflammation and venous thromboembolism (VTE) has attracted increasing research interest. Recently, the systemic inflammation response index (SIRI) has been proposed as a novel inflammatory biomarker, but its potential association with lower extremity deep venous thrombosis (LEDVT) has not been investigated. Thus, this study aimed to explore the association between SIRI and LEDVT risk in a large sample over a 10-year period (2012-2022).

METHODS

All hospitalized patients who underwent lower extremity compression ultrasonography (CUS) examinations were consecutively identified from our hospital information system database. Multivariate logistic regression analysis was used to investigate the association between SIRI and LEDVT risk. Sensitivity, restricted cubic spline and subgroup analyses were also performed.

RESULTS

In total, 12643 patients were included, and 1346 (10.6%) LEDVT events occurred. After full adjustment, a higher SIRI level was significantly associated with an increased risk of LEDVT (odds ratio [OR] = 1.098, 95% confidence interval [CI]: 1.068-1.128, p < 0.001), and patients in quartile 4 had a 2.563-fold higher risk of LEDVT than those in quartile 1 (95% CI: 2.064-3.182, p < 0.001). A nonlinear relationship was observed (P for nonlinearity < 0.001), with an inflection point of 4.17. Below this point, each unit increase in SIRI corresponded to a 35.3% increase in LEDVT risk (95% CI: 1.255-1.458, p < 0.001). No significant difference was found above the inflection point (OR = 1.015, 95% CI: 0.963-1.069, p = 0.582). Sensitivity and subgroup analyses confirmed the robustness of the association. This association also existed in both distal and proximal LEDVT.

CONCLUSION

A High SIRI is significantly associated with an increased risk of LEDVT in hospitalized patients. Given that the SIRI is a readily available biomarker in clinical settings, its potential clinical use deserves further exploration.

Routine Lower Extremity Screening Ultrasound Protocols in Trauma Patients Are Not Cost Effective

BACKGROUND

Despite prophylaxis, deep vein thrombosis (DVT) and pulmonary embolism remain dreaded complications following traumatic injury and are associated with significant morbidity and mortality. Screening ultrasound (US) protocols have been employed in trauma centers for early detection of lower extremity (LE) deep venous thrombosis. We hypothesized that screening lower extremity venous duplex US would not prove cost effective in our trauma population who receives early pharmacologic prophylaxis.

METHODS

Data was collected for one year on all adult trauma patients admitted to the trauma service from December 2019 to 2020. DVT screening US was obtained at 3 days after admission for patients with long bone or pelvic fracture, spinal cord injury, immobility, and/or spinal fracture requiring surgery. Screening US was obtained at 7 days for all others and repeated weekly until discharge. Data was retrospectively collected and analyzed.

RESULTS

Exactly 1365 patients met inclusion criteria with median ISS 12 (IQR, 9-17), median age 56 (IQR, 36-73 years), and with majority blunt injuries (90.7%). A total of 1369 screening US were performed finding 27 DVTs (2%). The total cost of screening for the year analyzed amounted to over $270,000 with 50.7 screening US needed to detect 1 DVT. This resulted in an average screening cost of over $10,000 for the detection of a single DVT.

DISCUSSION

In trauma patients receiving early pharmacologic prophylaxis, routine LE screening US protocols to detect LE DVT are not cost effective.

Improving VTE prophylaxis adherence among hospitalized adolescents using Human-Centered Design

Background/problem statement

Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality in the United States; however, compliance with VTE prophylaxis is poor. Most materials for education about VTE prophylaxis are oriented toward adults rather than adolescents, for whom VTE risks are lower and prophylaxis indications differ. We hypothesized that educational materials for adolescents could improve compliance with VTE prophylaxis, reduce nurse burden for initiating and maintaining VTE prevention practices, and reduce practice variation by standardizing the conversation between clinicians and patients.

Methods

A multidisciplinary team including physicians, nurses, quality experts, communication designers, service designers, and medical students applied a human-centered design (HCD) process to define, iteratively prototype, and test education tools for nurses assigned to adolescents. We piloted a suite of six educational tools for adolescent VTE prophylaxis to fit into the existing hospital workflow.

Results

An in-room poster was selected after 85% of nurses responded favorably to this intervention. Adolescent adherence with Intermittent Pneumatic Compression Device increased from 69% to 79%, attaining the benchmark goal of 78%. Staff reported greater confidence in educating adolescent patients after the intervention: 62% of nurses and 72% of residents.

Conclusion

An HCD process helped nurses improve VTE prophylaxis for adolescents with an in-room poster and messaging strategy. Engaging staff in the design increased receptivity and adoption. The piloted materials also helped to create an environment of shared priority among the clinicians.

Risk of Venous Thromboembolism Among Patients with Atopic Dermatitis: A Cohort Study in a US Administrative Claims Database

Introduction

Atopic dermatitis (AD) is associated with risk factors for venous thromboembolism (VTE). However, the risk of VTE among this population is unknown. The aim of this study was to assess the risk of VTE among adults with AD and compare the risk vs. matched non-AD controls.

Methods

This retrospective study used claims data from the IBM Watson MarketScan^® Commercial Claims and Encounters, Medicare Supplemental, and Medicaid databases to identify adults aged 18 years or older with AD. Incidence rates (IR) per 100 person-years (PY) of VTE were reported for three cohorts: overall AD, moderate-to-severe AD, and non-AD controls matched by age, sex, and calendar time to the overall cohort. Cox proportional hazards regression was used to estimate hazard ratios (HR) for VTE risk.

Results

Overall, 198,685 patients with AD were identified. Crude VTE IRs were 0.24 for AD overall, 0.31 for moderate-to-severe AD, and 0.25 for non-AD controls. VTE risk was similar in patients with AD vs. non-AD controls (partially adjusted HR 1.00, 95% confidence interval [CI] 0.92, 1.09). VTE risk was greater in patients with moderate-to-severe AD vs. non-AD controls in partially adjusted models (HR 1.24, 95% CI 1.13, 1.36), but not after adjustment for healthcare use and VTE risk factors (HR 0.95, 95% CI 0.85, 1.07).

Conclusions

AD was not an independent risk factor for VTE, and the risk of VTE among patients with AD was low. These findings provide valuable context for understanding VTE risk among patients with AD, which is particularly relevant as advanced therapies for the treatment of moderate to severe AD, such as janus kinase inhibitors, become available.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00538-4.

Treatment of Acute Venous Thromboembolism

"Acute venous thromboembolism is a common disease seen by nearly all hospitalists. The advent of low molecular weight heparin (LMWH) several decades ago ushered in the era of early hospital discharge and home treatment. More recently, the direct oral anticoagulants (DOACs) have further simplified outpatient treatment and some offer treatment without parenteral therapy. Use of DOACs for cancer-associated venous thromboembolism is emerging and is a welcome evolution of care to spare oncologic patients the burden of daily LMWH injections."

Prevention of health care associated venous thromboembolism through implementing VTE prevention clinical practice guidelines in hospitalized medical patients: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous VTE prevention clinical practice guidelines are available but not consistently implemented. This systematic review explored effectiveness of implementing VTE prevention clinical practice guidelines on VTE risk assessment and appropriateness of prophylaxis in hospitalized adult medical patients and identified the interventions followed to improve the adherence to these guidelines.

METHODS

Six electronic databases were searched for randomized controlled trials, clinical controlled trials, or pre/post evaluation studies up to January 2019. Studies identified were screened for eligibility by two reviewers independently. Data were extracted by two reviewers using a standardized form. Risk of bias was assessed using MINORS and the certainty of evidence for each outcome using the GRADE approach.

RESULTS

Of the 3537 records identified, 36 were eligible; eight studies were included for qualitative synthesis and four for meta-analysis. The meta-analysis of the studies assessing the impact of implementing VTE clinical practice guidelines favored appropriate prophylaxis (RR 1.67, 95% CI 1.41 to 1.97, 552 patients). Potential risk of bias was assessed to be low for 28% of the studies. However, using GRADE, the certainty of the evidence of all outcomes was rated very low quality.

CONCLUSIONS

The lack of randomized controlled trials in this area reduces the quality of the evidence available. The evidence from before-after studies suggests that the implementation of VTE clinical practice guidelines may increase the practice of VTE risk assessment and appropriate prophylaxis in hospitalized medical patients.

TRIAL REGISTRATION

PROSPERO CRD42018085506.

Thirty-day readmissions due to Venous thromboembolism in patients discharged with syncope

A recent study found that approximately 1 in every 6 patients hospitalized for the 1st episode of syncope had an underlying pulmonary embolism (PE). As current guidelines do not strongly emphasize evaluation for PE in the workup of syncope, we hypothesize that there might be a higher rate of 30-day readmission due to untreated venous thromboembolism (VTE). The objective of this study is to measure the 30-day readmission rate due to VTE and identify predictors of 30-day readmission with VTE among syncope patients. We identified patients admitted with syncope with ICD9 diagnoses code 780.2 in the Nationwide Readmission Database (NRD-2013), Healthcare Cost and Utilization Project (HCUP). The 30-day readmission rate was calculated using methods described by HCUP. Logistic-regression was used to identify predictors of 30-day readmission with VTE. Discharge weights provided by HCUP were used to generate national estimates. In 2013, NRD included 207,339 eligible patients admitted with syncope. The prevalence rates of PE and DVT were 1.1% and 1.4%, respectively. At least one syncope associated condition was present in 60.9% of the patients. Among the patients who were not diagnosed with VTE during index admission for syncope (N = 188,015), 30-day readmission rate with VTE was 0.5% (0.2% with PE and 0.4% with DVT). In conclusion, low prevalence of VTE in patients with syncope and extremely low 30-day readmission rate with VTE argues against missed diagnoses of VTE in index admission for syncope. These results warrant further studies to determine clinical impact of work up for PE in syncope patients without risk factors.