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Sanchez O, Roy PM, Gaboreau Y, Schmidt J, Moustafa F, Benmaziane A, Élias A, Espitia O, Sevestre MA, Couturaud F, Mahé I. [Translation into French and republication of: "Home treatment for patients with cancer-associated venous thromboembolism"]. Rev Med Interne 2024; 45:226-238. [PMID: 38632029 DOI: 10.1016/j.revmed.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 04/19/2024]
Abstract
Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.
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Affiliation(s)
- Olivier Sanchez
- Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France; F-Crin INNOVTE network, Saint-Étienne, France.
| | - Pierre-Marie Roy
- Service de médecine d'urgence, CHU d'Angers, université d'Angers, UMR MitoVasc CNRS 6015-Inserm 1083, équipe Carme, Angers, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Yoann Gaboreau
- Département de médecine générale, faculté de médecine, Techniques de l'ingénierie médicale et de la complexité (Timc), université Grenoble Alpes, Grenoble, France
| | - Jeannot Schmidt
- Service d'urgence, CHU de Clermont-Ferrand, Lapsco-UMR UBP-CNRS 6024, université Clermont Auvergne, Clermont-Ferrand, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont-Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-Crin INNOVTE network, Saint-Étienne, France
| | | | - Antoine Élias
- Département de cardiologie et de médecine vasculaire, délégation Recherche clinique et innovation, centre hospitalier intercommunal de Toulon La Seyne-sur-Mer, Toulon, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Olivier Espitia
- Service de médecine interne et vasculaire, Institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087 - CNRS UMR 6291, Team III Vascular & pulmonary diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de médecine vasculaire, ÉA Chimère 7516, CHU d'Amiens-Picardie, Amiens, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Francis Couturaud
- Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304 - Getbo, université de Brest, Brest, France; F-Crin INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, Innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-Crin INNOVTE network, Saint-Étienne, France
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Chaibi S, Roy PM, Guénégou AA, Tran Y, Hugli O, Penaloza A, Couturaud F, Tromeur C, Szwebel TA, Pernod G, Elias A, Ghuysen A, Benhamou Y, Falvo N, Juchet H, Nijkeuter M, Mairuhu R, Faber LM, Mahé I, Montaclair K, Planquette B, Jimenez D, Huisman MV, Klok FA, Sanchez O. Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial. Thromb Res 2024; 235:79-87. [PMID: 38308882 DOI: 10.1016/j.thromres.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.
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Affiliation(s)
- Sérine Chaibi
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, Angers F-49000, France; Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Armelle Arnoux Guénégou
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, INRIA, HeKA, Paris, France
| | - Yohann Tran
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, Paris, France
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Andréa Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium; UCLouvain, Brussels, Belgium
| | - Francis Couturaud
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Cécile Tromeur
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, Cochin Hospital, APHP, Paris, France
| | - Gilles Pernod
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Vascular Medicine, CHU Grenoble Alpes, Grenoble, France; University Grenoble Alpes, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Antoine Elias
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology and Vascular Medicine, Sainte Musse Hospital, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | - Alexandre Ghuysen
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Ygal Benhamou
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, CHU Charles Nicolle, Rouen, France; Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France
| | - Nicolas Falvo
- F-CRIN, INNOVTE, Saint-Etienne, France; Vascular Medicine Department, CHU Dijon, Dijon, France
| | - Henry Juchet
- Emergency Department, CHU Toulouse, Toulouse, France
| | - Mathilde Nijkeuter
- Department of emergency medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronne Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, DTN, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, Louis Mourier Hospital, AP-HP, Colombes, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Karine Montaclair
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology, CH Le Mans, Le Mans, France
| | - Benjamin Planquette
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - David Jimenez
- Respiratory Department and Medicine Department, Ramon y Cajal Hospital (IRYCIS) and Alcala University, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Federikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier Sanchez
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France.
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Sanchez O, Roy PM, Gaboreau Y, Schmidt J, Moustafa F, Benmaziane A, Elias A, Espitia O, Sevestre MA, Couturaud F, Mahé I. Home treatment for patients with cancer-associated venous thromboembolism. Arch Cardiovasc Dis 2024; 117:16-28. [PMID: 38092577 DOI: 10.1016/j.acvd.2023.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home.
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Affiliation(s)
- Olivier Sanchez
- Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Pierre-Marie Roy
- Service de médecine d'urgences, CHU Angers, Université d'Angers, UMR MitoVasc CNRS 6015 - Inserm 1083, équipe CARME, Angers, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Yoann Gaboreau
- Département de médecine générale, faculté de médicine, techniques de l'ingénierie médicale et de la complexité (TIMC), université Grenoble-Alpes, Grenoble, France
| | - Jeannot Schmidt
- Service d'urgence, CHU de Clermont-Ferrand, LAPSCO-UMR UBP-CNRS 6024, Université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | | | - Antoine Elias
- Département de cardiologie et de médecine vasculaire, délégation recherche clinique et innovation, centre hospitalier intercommunal Toulon La Seyne-sur-Mer, Toulon, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Espitia
- Service de médecine interne et vasculaire, institut du thorax, Nantes université, CHU de Nantes, Inserm UMR 1087 -CNRS UMR 6291, Team III Vascular & Pulmonary diseases, Nantes, France
| | - Marie-Antoinette Sevestre
- Service de médecine vasculaire, EA Chimère 7516 CHU d'Amiens-Picardie, Amiens, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Francis Couturaud
- Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304 -GETBO, université de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Etienne, France
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Guman NAM, Kaptein FHJ, Lohle SB, Mairuhu ATA, Klok FA, Huisman MV, Kamphuisen PW, van Es N. Discharge from the emergency department and outpatient clinic in cancer patients with acute symptomatic and incidental pulmonary embolism: A multicenter retrospective cohort study. Thromb Res 2024; 233:181-188. [PMID: 38101191 DOI: 10.1016/j.thromres.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/27/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND It is unclear how often cancer patients with acute pulmonary embolism (PE) are discharged from the emergency department (ED) or outpatient clinic and whether direct discharge is safe. We assessed treatment setting and early safety outcomes in cancer patients with acute symptomatic and incidental PE. METHODS Cancer patients diagnosed with PE at the ED or outpatient clinic between August 2017 and May 2021 were included in Four Cities VTE Cancer, a Dutch multicenter retrospective cohort study. The main outcome was direct discharge versus hospitalization. Safety outcomes were cumulative 14-day mortality and PE-related readmission incidences. RESULTS We included 602 patients (median age 71 years; 49.5 % female) of whom 285 (47.3 %) were discharged directly and 317 (52.7 %) were hospitalized. The cumulative 14-day mortality incidence was 0.7 % (95 % CI, 0.1-2.4 %) in patients discharged directly and 9.0 % (95 % CI, 6.2-12.5 %) in those hospitalized. The cumulative 14-day PE-related readmission incidence was 1.8 % (95 % CI, 0.7-3.9 %) and 1.4 % (95 % CI, 0.5-3.3 %) in directly discharged and hospitalized patients, respectively. Of the 220 patients with incidental PE, 180 (81.8 %) were discharged directly compared to 105 of 382 (27.5 %) patients with symptomatic PE (P < 0.001). Mortality and readmission incidences in symptomatic and incidental PE were consistent with the main analysis. CONCLUSIONS About 28 % and 82 % of cancer patients with symptomatic or incidental PE, respectively, were discharged directly, with low 14-day mortality and PE-related readmission incidences. These data underline the need for PE risk stratification in oncological populations and suggest that clinicians successfully identify a proportion of patients in whom direct discharge is safe.
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Affiliation(s)
- N A M Guman
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands.
| | - F H J Kaptein
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S B Lohle
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands
| | - A T A Mairuhu
- Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P W Kamphuisen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands
| | - N van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands
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Sánchez-Cánovas M, Jimenez-Fonseca P, Fernández Garay D, Cejuela Solís M, Casado Elía D, Coma Salvans E, de la Haba Vacas I, Gómez Sánchez D, Fernández Montés A, Morales Giménez R, Biosca Gómez de Tejada M, Arrazubi Arrula V, Sequero López S, Otero Candelera R, Sánchez Cendra C, Justo de la Peña M, Moreno Muñoz D, Orillo Sarmiento M, Martínez de Castro E, García Escobar I, Bernal Vidal A, Ortega Moran L, Muñoz Martín AJ, Sánchez Bayona R, Martínez Ortiz MJ, Ayala de la Peña F, Vicente V, Carmona-Bayonas A. Prediction of serious complications in patients with pulmonary thromboembolism and solid cancer: Validation of the EPIPHANY Index in a prospective cohort of patients from the PERSEO study. PLoS One 2023; 18:e0266305. [PMID: 37159465 PMCID: PMC10168567 DOI: 10.1371/journal.pone.0266305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/11/2023] [Indexed: 05/11/2023] Open
Abstract
INTRODUCTION There is currently no validated score capable of classifying cancer-associated pulmonary embolism (PE) in its full spectrum of severity. This study has validated the EPIPHANY Index, a new tool to predict serious complications in cancer patients with suspected or unsuspected PE. METHOD The PERSEO Study prospectively recruited individuals with PE and active cancer or receiving antineoplastic therapy from 22 Spanish hospitals. The estimation of the relative frequency θ of complications based on the EPIPHANY Index categories was made using the Bayesian alternative for the binomial test. RESULTS A total of 900 patients, who were diagnosed with PE between October 2017 and January 2020, were enrolled. The rate of serious complications at 15 days was 11.8%, 95% highest density interval [HDI], 9.8-14.1%. Of the EPIPHANY low-risk patients, 2.4% (95% HDI, 0.8-4.6%) had serious complications, as did 5.5% (95% HDI, 2.9-8.7%) of the moderate-risk participants and 21.0% (95% HDI, 17.0-24.0%) of those with high-risk episodes. The EPIPHANY Index was associated with overall survival (OS) in patients with different risk levels: median OS was 16.5, 14.4, and 4.4 months for those at low, intermediate, and high risk, respectively. Both the EPIPHANY Index and the Hestia criteria exhibited greater negative predictive value and a lower negative likelihood ratio than the remaining models. The incidence of bleeding at 6 months was 6.2% (95% HDI, 2.9-9.5%) in low/moderate-risk vs 12.7% (95% HDI, 10.1-15.4%) in high-risk (p-value = 0.037) episodes. Of the outpatients, serious complications at 15 days were recorded in 2.1% (95% HDI, 0.7-4.0%) of the cases with EPIPHANY low/intermediate-risk vs 5.3% (95% HDI, 1.7-11.8%) in high-risk cases. CONCLUSION We have validated the EPIPHANY Index in patients with incidental or symptomatic cancer-related PE. This model can contribute to standardize decision-making in a scenario lacking quality evidence.
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Affiliation(s)
- Manuel Sánchez-Cánovas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Murcia, Spain
| | - Paula Jimenez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | | | - Mónica Cejuela Solís
- Medical Oncology Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Diego Casado Elía
- Medical Oncology Department, Complejo Hospitalario de Salamanca, Salamanca, Spain
| | - Eva Coma Salvans
- Medical Oncology Department, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - Irma de la Haba Vacas
- Medical Oncology Department, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - David Gómez Sánchez
- Medical Oncology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Ana Fernández Montés
- Medical Oncology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | | | | | | | | | | | | | | | | | | | - Eva Martínez de Castro
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Ignacio García Escobar
- Medical Oncology Department, Hospital General Universitario Virgen de las Nieves, Granada, Spain
| | - Alejandro Bernal Vidal
- Medical Oncology Department, Hospital Universitario San Juan de Alicante, Sant Joan d'Alacant, Spain
| | - Laura Ortega Moran
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Andrés J Muñoz Martín
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | | | - Vicente Vicente
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Murcia, Spain
| | - Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Murcia, Spain
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Ryan ES, Havrilesky LJ, Salinaro JR, Davidson BA. Cost-Effectiveness of Venous Thromboembolism Prophylaxis During Neoadjuvant Chemotherapy for Ovarian Cancer. JCO Oncol Pract 2021; 17:e1075-e1084. [PMID: 33914645 DOI: 10.1200/op.20.00783] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Two recent clinical trials have demonstrated that direct oral anticoagulants (DOACs) are effective as venous thromboembolism (VTE) prophylaxis in patients with moderate-to-high risk ambulatory cancer initiating chemotherapy. Patients with advanced ovarian cancer receiving neoadjuvant chemotherapy are at particularly increased risk of VTE. We performed a cost-effectiveness analysis from a health system perspective to determine if DOACs are a feasible prophylactic strategy in this population. METHODS A simple decision tree was created from a health system perspective, comparing two strategies: prophylactic DOAC taken for 18 weeks during chemotherapy versus no VTE prophylaxis. Rates of VTE (7.3% DOAC v 13.6% no treatment), major bleeding (2.6% v 1.3%), and clinically relevant nonmajor bleeding (4.6% v 3.3%) were modeled. Cost estimates were obtained from wholesale drug costs, published studies, and Medicare reimbursement data. Probabilistic, one-way, and two-way sensitivity analyses were performed. RESULTS In the base case model, DOAC prophylaxis is more costly and more effective than no therapy (incremental cost-effectiveness ratio = $256,218 in US dollars/quality-adjusted life year). In one-way sensitivity analyses, reducing the DOAC cost by 32% or raising the baseline VTE rate above 18% renders this strategy potentially cost-effective with an incremental cost-effectiveness ratio below $150,000 in US dollars/quality-adjusted life year. CONCLUSION Further confirmation of the true baseline VTE rate among women initiating neoadjuvant chemotherapy for ovarian cancer will determine whether prophylactic dose DOAC is a value-based strategy. Less costly VTE prophylaxis options such as generic DOACs (once available) and aspirin also warrant investigation.
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Affiliation(s)
- Emma S Ryan
- Duke University School of Medicine, Durham, NC
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Julia R Salinaro
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Chen K, Desai K, Sureshanand S, Adelson K, Schwartz JI, Gross CP, Chaudhry SI. Creating and Validating a Predictive Model for Suitability of Hospital at Home for Patients With Solid-Tumor Malignancies. JCO Oncol Pract 2021; 17:e556-e563. [PMID: 33417488 DOI: 10.1200/op.20.00663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.
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Affiliation(s)
- Kevin Chen
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Keval Desai
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Soundari Sureshanand
- Joint Data Analytics Team, Yale University, New Haven, CT.,Yale Center for Clinician Investigation, New Haven, CT
| | - Kerin Adelson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,Smilow Cancer Hospital at Yale New Haven Health, New Haven, CT
| | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
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Klok FA, Huisman MV. When I treat a patient with acute pulmonary embolism at home. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:190-194. [PMID: 33275689 PMCID: PMC7727561 DOI: 10.1182/hematology.2020000106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Home treatment is feasible and safe in selected patients with acute pulmonary embolism (PE) and is associated with a considerable reduction in health care costs. When establishing a PE outpatient pathway, 2 major decisions must be made. The first one concerns the selection of patients for home treatment. The second one involves dedicated outpatient follow-up including sufficient patient education and facilities for specialized follow-up visits. Current evidence points toward the use of either the Hestia criteria or Pulmonary Embolism Severity Index with/without assessment of the right ventricular function to select patients for home treatment, depending on local preferences. Results from ongoing trials are expected to enforce current guideline recommendations on home treatment and pave the way for more broad application of this elegant and cost-effective management option for patients with acute PE.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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9
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van Dam LF, Kroft LJM, van der Wal LI, Cannegieter SC, Eikenboom J, de Jonge E, Huisman MV, Klok FA. Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease? Thromb Res 2020; 193:86-89. [PMID: 32531548 PMCID: PMC7274953 DOI: 10.1016/j.thromres.2020.06.010] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 infections are associated with a high prevalence of venous thromboembolism, particularly pulmonary embolism (PE). It is suggested that COVID-19 associated PE represents in situ immunothrombosis rather than venous thromboembolism, although the origin of thrombotic lesions in COVID-19 patients remains largely unknown. METHODS In this study, we assessed the clinical and computed tomography (CT) characteristics of PE in 23 consecutive patients with COVID-19 pneumonia and compared these to those of 100 consecutive control patients diagnosed with acute PE before the COVID-19 outbreak. Specifically, RV/LV diameter ratio, pulmonary artery trunk diameter and total thrombus load (according to Qanadli score) were measured and compared. RESULTS We observed that all thrombotic lesions in COVID-19 patients were found to be in lung parenchyma affected by COVID-19. Also, the thrombus load was lower in COVID-19 patients (Qanadli score -8%, 95% confidence interval [95%CI] -16 to -0.36%) as was the prevalence of the most proximal PE in the main/lobar pulmonary artery (17% versus 47%; -30%, 95%CI -44% to -8.2). Moreover, the mean RV/LV ratio (mean difference -0.23, 95%CI -0.39 to -0.07) and the prevalence of RV/LV ratio >1.0 (prevalence difference -23%, 95%CI -41 to -0.86%) were lower in the COVID-19 patients. CONCLUSION Our findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19, fuelling the discussion on its pathophysiology.
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Affiliation(s)
- L F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L I van der Wal
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Hendriks SV, den Exter PL, Zondag W, Brouwer R, Eijsvogel M, Grootenboers MJ, Faber LM, Heller-Baan R, Hofstee HMA, Iglesias del Sol A, Kruip MJHA, Mairuhu ATA, Melissant CF, Peltenburg HG, van de Ree MA, Serné EH, Huisman MV, Klok FA. Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule. Thromb Haemost 2020; 120:1217-1220. [DOI: 10.1055/s-0040-1713170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background The Hestia criteria can be used to select pulmonary embolism (PE) patients for outpatient treatment. The subjective Hestia criterion “medical/social reason for admission” allows the treating physician to consider any patient-specific circumstances in the final management decision. It is unknown how often and why this criterion is scored.
Methods This is a patient-level post hoc analysis of the combined Hestia and Vesta studies. The main outcomes were the frequency of all scored Hestia items in hospitalized patients and the explicit reason for scoring the subjective criterion. Hemodynamic parameters and computed tomography-assessed right ventricular (RV)/left ventricular (LV) ratio of those only awarded with the subjective criterion were compared with patients treated at home.
Results From the 1,166 patients screened, data were available for all 600 who were hospitalized. Most were hospitalized to receive oxygen therapy (45%); 227 (38%) were only awarded with the subjective criterion, of whom 51 because of “intermediate to intermediate-high risk PE.” Compared with patients with intermediate risk PE (RV/LV ratio > 1.0) treated at home (179/566, 32%), hospitalized patients with only the subjective criterion had a higher mean RV/LV ratio (mean difference +0.30, 95% confidence interval [CI] 0.19–0.41) and a higher heart rate (+18/min, 95% CI 10–25). No relevant differences were observed for other hemodynamic parameters.
Conclusion The most frequent reason for hospital admission was oxygen therapy. In the decision to award the subjective criterion as sole argument for admission, the severity of the RV overload and resulting hemodynamic response of the patient was taken into account rather than just abnormal RV/LV ratio.
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Affiliation(s)
- Stephan V. Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Paul L. den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Zondag
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Brouwer
- Department of Internal Medicine, Reinier de Graaff Gasthuis, Delft, The Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Laura M. Faber
- Department of Pulmonary Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Roxanne Heller-Baan
- Department of Pulmonary Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Herman M. A. Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Marieke J. H. A. Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert T. A. Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | | | - Henny G. Peltenburg
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | | | - Erik H. Serné
- Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Pfaundler N, Limacher A, Stalder O, Méan M, Rodondi N, Baumgartner C, Aujesky D. Prognosis in patients with cancer-associated venous thromboembolism: Comparison of the RIETE-VTE and modified Ottawa score. J Thromb Haemost 2020; 18:1154-1161. [PMID: 32124545 DOI: 10.1111/jth.14783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The RIETE-VTE score was derived to risk-stratify patients with cancer-associated venous thromboembolism (CAT). OBJECTIVES To externally validate the RIETE-VTE score and to compare its prognostic performance with the modified Ottawa score. PATIENTS/METHODS We studied 178 elderly patients with CAT in a prospective multicenter cohort and assessed 30-day all-cause mortality, 90-day overall complications (mortality, major bleeding, or venous thromboembolism [VTE] recurrence), and 6-month VTE recurrence. Patients were stratified into RIETE-VTE and modified Ottawa score risk classes (low, intermediate, high). We compared the discriminative power (area under the receiver operating characteristic [ROC] curve) to predict mortality, overall complications, and VTE recurrence. RESULTS Fifteen patients (8.4%) died within 30 days, 42 (23.6%) experienced an overall complication by day 90, and 6 (3.4%) had recurrent VTE within 6 months. The RIETE-VTE and the modified Ottawa score classified similar proportions of patients as low risk (35.4% versus 31.5%; P = .37). No low-risk patient died within 30 days. Low-risk patients identified by the RIETE-VTE and modified Ottawa score had similar rates of overall complications (7.9% versus 8.9%) and VTE recurrence (1.6% versus 1.8%). The modified Ottawa score and the RIETE-VTE score had similar areas under the ROC curve for predicting all-cause mortality (0.84 versus 0.75; P = .21), overall complications (0.74 versus 0.68; P = .26), and VTE recurrence (0.67 versus 0.64; P = .78). CONCLUSIONS Both the RIETE-VTE and modified Ottawa score accurately identified elderly patients with CAT who are at low risk for short-term mortality and who are potential candidates for outpatient care.
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Affiliation(s)
- Nubio Pfaundler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Odile Stalder
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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