Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Population-Based Disparities in Inferior Vena Cava Filter Procedures Among Medicare Enrollees With Acute Venous Thromboembolism

PURPOSE

Venous thromboembolism (VTE) imposes a significant clinical and financial burden on patients and society. Inferior vena cava filters (IVCFs) are considered for patients with absolute contraindications or failures of anticoagulation. However, studies examining the population-based disparities of IVCF placement and retrieval are limited. The association between patient and clinical characteristics in the likelihood of and time to IVCF placement and retrievals in a nationally representative cohort was examined.

METHODS

Medicare patients aged ≥65 years with index VTE claims between 2015 and 2018 were followed through 2019 to identify IVCF placements and retrievals. Rates were compared using survival analysis methods.

RESULTS

Of the 516,978 patients with VTE diagnoses, 5,864 (1.1%) had IVCFs placed, and 1,884 (32.1%) of those underwent retrieval procedures. Placement and retrieval rates varied significantly by demographics, comorbidity burden, and geographic region. From Cox regression, older age (hazard ratio [HR], 1.26; P < .0001), higher baseline comorbidity (Elixhauser) score (HR, 1.07; P < .0001), and outpatient (vs inpatient) site of VTE service (HR, 2.11; P < .0001) were associated with increased frequency of IVCF placement. The rate of retrieval was significantly lower for men (HR, 0.83; P = .0393), patients with higher comorbidity scores (HR, 0.95; P = .0037), and those with outpatient (vs inpatient) VTE sites of service (HR, 0.77; P = .0173). Neither facility- nor county-level characteristics were significantly associated with placements or retrievals.

CONCLUSIONS

This large cohort of Medicare beneficiaries with newly diagnosed VTE demonstrated inequities in IVCF placement and retrieval.

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis

BACKGROUND

Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement.

METHOD

In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE.

RESULTS

We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance.

CONCLUSIONS

Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review

OBJECTIVE

To characterize racial/ethnic and insurance disparities in the utilization of healthcare services among US adults with traumatic brain injury (TBI).

METHODS

The PubMed database was used to search for articles that directly examined the association between race/ethnicity and insurance disparities and healthcare utilization among patients with TBI. Eleven articles that met the criteria and were published between June 2011 and June 2016 were finally included in the review.

RESULTS

Lack of insurance was significantly associated with decreased use of inhospital and posthospital healthcare services among patients with TBI. However, mixed results were reported for the associations between insurance types and healthcare utilization. The majority of studies reported that racial/ethnic minorities were less likely to use inhospital and posthospital healthcare services, while some studies did not indicate any significant relation between race/ethnicity and healthcare utilization among patients with TBI.

CONCLUSIONS

This review provides evidence of a relation between insurance status and healthcare utilization among US adults with TBI. Insurance status may also account for some portion of the relation between race/ethnicity and healthcare utilization.

Retrospective analysis of outcomes following inferior vena cava (IVC) filter placement in a managed care population

The role of inferior vena cava filter (IVC) filters for prevention of pulmonary embolism (PE) is controversial. This study evaluated outcomes of IVC filter placement in a managed care population. This retrospective cohort study evaluated data for individuals with Humana healthcare coverage 2013-2014. The study population included 435 recipients of prophylactic IVC filters, 4376 recipients of therapeutic filters, and two control groups, each matched to filter recipients. Patients were followed for up to 2 years. Post-index anticoagulant use, mortality, filter removal, device-related complications, and all-cause utilization. Adjusted regression analyses showed a positive association between filter placement and anticoagulant use at 3 months: odds ratio (ORs) 3.403 (95% CI 1.912-6.059), prophylactic; OR, 1.356 (95% CI 1.164-1.58), therapeutic. Filters were removed in 15.67% of prophylactic and 5.69% of therapeutic filter cases. Complication rates were higher with prophylactic procedures than with therapeutic procedures and typically exceeded 2% in the prophylactic group. Each form of filter placement was associated with increases in all-cause hospitalization (regression coefficient 0.295 [95% CI 0.093-0.498], prophylactic; 0.673 [95% CI 0.547-0.798], therapeutic) and readmissions (OR 2.444 [95% CI 1.298-4.602], prophylactic; 2.074 [95% CI 1.644-2.616], therapeutic). IVC filter placement in this managed care population was associated with increased use of anticoagulants and greater healthcare utilization compared to controls, low rates of retrieval, and notable rates of device-related complications, with effects especially pronounced in assessments of prophylactic filters. These findings underscore the need for appropriate use of IVC filters.

Patient and hospital characteristics predictive of inferior vena cava filter usage in venous thromboembolism patients: A study from the 2013 to 2014 Nationwide Readmissions Database

To examine the association between patient and hospital characteristics and inferior vena cava filter (IVCF) utilization in patients with venous thromboembolism (VTE).The 2013 to 2014 Nationwide Readmissions Database was used to define a cohort of patients with VTE aged ≥18 after a primary VTE diagnosis. Comorbidities of interest were classified via diagnosis codes and IVCF placement was identified via procedure code. Chi square analysis tested differences between patient and hospital-level characteristics and whether or not IVCFs were placed. A hierarchical logistic regression model estimated the relationship between patient-level factors (demographics, socioeconomic status, comorbidities), hospital-level factors (bed size, teaching status, urbanity) and whether or not IVCFs were placed. Additional models were specified to examine goodness of fit across methodological alternatives.There were 212,395 VTE hospitalizations, with 12.18% (n = 25,877) receiving IVCF placement. There were significant differences between those who did and did not receive IVCF placement; notably, those receiving IVCFs were older (P < .001), had Medicare insurance more than private (P < .001), longer lengths of stay (P < .001), and were in privately owned hospitals (P < .001). IVCF placement remained significantly associated with patient and hospital-level characteristics following multivariate adjustment via hierarchical logistic regression; notably, age >80 (adjusted Odds Ratio [aOR]: 2.53, 95% confidence interval [CI]: 2.25-2.85), ≥13 comorbid conditions (aOR: 3.85, 95% CI: 3.25-4.27), and privately owned hospitals (aOR: 1.21, 95% CI: 1.08-1.36). Optimal goodness-of-fit was achieved with a combination of random effects and patient-level fixed effects.These findings provide evidence that combinations of patient and hospital-level factors are related to whether patients with VTE receive IVCFs.

Inferior vena cava filter use and patient safety: legacy or science?

There has been a dramatic increase in vena cava filter (VCF) use over the past 20 years in the absence of evidence that filters provide a net patient benefit or are required in most cases. This increase is largely attributable to the availability of retrievable filters and expanded indications, particularly as primary prophylaxis in patients thought to be at high risk of pulmonary embolism. Substantial variability in VCF use, unrelated to patient clinical factors, has been shown between hospitals, from region to region, and among various countries. Despite the lack of direct evidence for the benefit of VCFs for any indication, it is appropriate to insert a retrievable VCF in patients with a recent proximal deep vein thrombosis and an absolute contraindication to therapeutic anticoagulation and then to remove the filter once the bleeding risk decreases and the patient has been anticoagulated. Unfortunately, a high proportion of retrievable filters are not removed, even after the reason for their placement has long passed. Retrievable filters are associated with substantial rates of complications if they are not removed, including penetration of the vena caval wall, fracture and embolization of filter fragments, and caval occlusion. Patient safety priorities and medical-legal concerns mandate careful selection of patients for VCF placement and removal shortly after anticoagulation has been initiated.

Impact of Physician Education and a Dedicated Inferior Vena Cava Filter Tracking System on Inferior Vena Cava Filter Use and Retrieval Rates Across a Large US Health Care Region

PURPOSE

To evaluate the effects of physician familiarity with current evidence and guidelines on inferior vena cava (IVC) filter use and the availability of IVC filter tracking infrastructure on retrieval rates.

MATERIALS AND METHODS

Fourteen continuing medical education-approved in-hospital grand rounds covering evidence-based review of the literature on IVC filter efficacy, patient-centered outcomes, guidelines for IVC filter indications, and complications were performed across a large United States (US) health care region serving more than 3.5 million members. A computer-based IVC filter tracking system was deployed simultaneously. IVC filter use, rates of attempted retrieval, and fulfillment of guidelines for IVC filter indications were retrospectively evaluated at each facility for 12 months before intervention (n = 427) and for 12 months after intervention (n = 347).

RESULTS

After education, IVC filter use decreased 18.7%, with a member enrollment-adjusted decrease of 22.2%, despite an increasing IVC filter use trend for 4 years. Reduction in IVC filter use at each facility strongly correlated with physician attendance at grand rounds (r = -0.69; P = .007). Rates of attempted retrieval increased from 38.9% to 54.0% (P = .0006), with similar rates of successful retrieval (82.3% before education and 85.8% after education on first attempt). Improvement in IVC filter retrieval attempts correlated with physician attendance at grand rounds (r = 0.51; P = .051). IVC filter dwell times at first retrieval attempt were similar (10.2 wk before and 10.8 wk after).

CONCLUSIONS

Physician education dramatically reduced IVC filter use across a large US health care region, and represents a learning opportunity for physicians who request and place them. Education and a novel tracking system improved rates of retrieval for IVC filter devices.

The Influence of Insurance Status on the Surgical Treatment of Acute Spinal Fractures

STUDY DESIGN

A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and 2011.

OBJECTIVE

The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma.

METHODS

Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery.

RESULTS

Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance.

CONCLUSION

Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI.

Inferior vena cava filters: current best practices

Venous thromboembolism (VTE) is a common cause of inpatient and outpatient morbidity and mortality. While anticoagulant therapy is considered the primary means of prevention and treatment of VTE, inferior vena cava filters (IVCFs) are often used as an alternative or adjunct to anticoagulation. With the advent of retrievable filters indications have liberalized, to include placement for primary prophylaxis in high-risk patients. However, this practice is based on limited evidence supporting their efficacy in preventing clinically relevant outcomes. Since indiscriminate use of IVCFs can be associated with net patient harm and increased health care costs, knowledge of the literature surrounding IVCF utilization is critical for providers to adopt best practices. In this review, we will provide an overview of the literature as it relates to specific clinical questions that arise when considering IVCF utilization in the prevention and treatment of VTE. Practice-based recommendations will be reviewed to provide the clinician with guidance on challenging clinical scenarios.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations

The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.

Clinical review: inferior vena cava filters in the age of patient-centered outcomes

Inferior vena cava filter (IVCF) use continues to increase in the United States (US) despite questionable clinical benefit and increasing concerns over long-term complications. For this review we comprehensively examine the randomized, prospective data on IVC filter efficacy, compare relative rates of IVCF placement in the US and Europe, compare commonly considered guidelines for IVCF indications, and the current data on IVCF complications. Searches of MEDLINE and Cochrane databases were conducted for randomized prospective IVCF studies. Only three randomized prospective studies for IVCFs were identified. Commonly cited IVCF guidelines were reviewed with attention to their evolution over time. No evidence has shown a survival benefit with IVCF use. Despite this, continued rising utilization, especially for primary prophylactic indications, is concerning, given increasing evidence of long-term filter-related complications. This is particularly noted in the US where IVCF placements for 2012 are projected to be 25 times that of an equivalent population in Europe (224,700 versus 9,070). Pending much-needed randomized controlled trials that also evaluate long-term safety, we support the more stringent American College of Chest Physicians (ACCP) guidelines for IVCF placement indications and advocate a close, structured follow-up of retrievable IVCFs to improve filter retrieval rates.