SPSP Acute Adult Venous Thromboembolism bibliography

s 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. 35 Flanders S and Gunn S. Pulmonary issues in acute and critical care: pulmonary embolism and ventilator-induced lung injury. Critical Care Nursing Clinics of North America. 2011;23(4):617-34. Many patients admitted to acute care hospitals are at risk for VTE. Nurses play a pivotal role in prevention of VTE events by assessing risk and implementing prophylactic interventions, promptly recognizing and reacting to signs and symptoms of DVT and PE, and collaborating with other team members to ensure rapid treatment ensues. When patients require mechanical ventilation, nurses need to remain alert for complications indicative of VILI, effectively communicate assessment findings to other team members and confidently implement nursing and ordered medical interventions to promote the best possible patient outcomes. 72 Fumery M, Xiaocang C, Dauchet L, Gower-Rousseau C, Peyrin-Biroulet L and Colombel JF. Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: A metaanalysis of observational studies. Journal of Crohn's and Colitis. 2014;8(6):469-479. Objective: Patients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial. Design: We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD. Results: 33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67-2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91-1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78-3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95-3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19-1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78-6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93-1.14). Conclusion: The risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia. © 2013 European Crohn's and Colitis Organisation. 11 Galanis T and Merli GJ. New oral anticoagulants: prevention of VTE in phase III studies in total joint replacement surgery and the hospitalized medically-ill patients. Journal of Thrombosis & Thrombolysis. 2013;36(2):141-8. Effective venous thromboembolism prophylaxis in hospitalized medically-ill patients and those undergoing orthopaedic surgery remains a challenge for clinicians in the United States. Several new oral anticoagulants, which either directly inhibit the activity of thrombin or factor Xa have been developed and studied for venous thromboembolism (VTE) prevention in phase III trials in these patient populations. These new medications demonstrate several advantages over traditional anticoagulants, including their administration at fixed doses with no requirement for routine coagulation monitoring. Such advantages may potentially be offset by the lack of well-studied methods to reverse their anticoagulant effects and the potential need for standardized testing to monitor their activity in certain situations. This review will provide an overview of the clinical trial results of dabigatran, apixaban and rivaroxaban for VTE prevention in the orthopaedic and medically-ill hospitalized patients. 123 Gaston S, White S and Misan G. Venous thromboembolism (VTE) risk assessment and prophylaxis: A comprehensive systematic review of the facilitators and barriers to healthcare worker compliance with clinical practice guidelines in the acute care setting. JBI Database of Systematic Reviews and Implementation Reports. 2012;10(57):3812-3893. Background: Even though guidelines for venous thromboembolism risk assessment and prophylaxis are available, patients with identifiable risk factors admitted to acute hospitals are not receiving appropriate prophylaxis. The incidence of venous thromboembolism in hospitalized patients is higher than that of people living in the community who have similar demographics. Knowledge of barriers to healthcare professional compliance with clinical practice guidelines and facilitators to improve compliance will aid appropriate use of venous thromboembolism clinical practice guidelines. Objectives: The main objective of this review was to identify the barriers and facilitators to healthcare professional compliance with clinical practice guidelines for venous thromboembolism assessment and prophylaxis. Inclusion criteria Types of participants: Studies were considered for inclusion regardless of the designation of the healthcare professional involved in the acute care setting. Focus of the review: The focus of the review was compliance with venous thromboembolism clinical practice guidelines and identified facilitators and barriers to clinical use of these guidelines. Types of studies: Any experimental, observational studies or qualitative research studies were considered for inclusion in this review. Types of outcomes: The outcomes of interest were compliance with venous thromboembolism guidelines and identified barriers and facilitators to compliance. Search strategy: A comprehensive, three-step search strategy was conducted for studies published from May 2003 to November 2011, aimed to identify both published and unpublished studies in the English language across six major databases. Methodological quality: Retrieved papers were assessed by two independent reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection: Both quantitative and qualitative data were extracted from papers included in the review using standardized data tools from the Joanna Briggs Institute. Data synthesis: Quantitative data was pooled using narrative summary due to heterogeneity in the ways in which data was reported. Qualitative data was pooled using Joanna Briggs Institute software. Results: Twenty studies were included in the review with methodological quality ranging from low to high. Reported compliance at baseline ranged from 6.25% to 70.4% and compliance postintervention ranged from 36% to 100%. Eight main categories of barriers and nine main categories of facilitators were identified. The quantitative and qualitative studies identified very similar barriers and facilitators which fell under the same categories. The studies all had components of education involved in their intervention and the review found that passive dissemination or one mode of intervention was not enough to affect and sustain change in clinical practice. Conclusions: This review identified 20 studies that assessed compliance with venous thromboembolism clinical practice guidelines, and identified barriers and facilitators to that compliance. The studies showed that many different forms of intervention can improve compliance with clinical practice guidelines. They provided evidence that interventions can be developed for the specific audience and setting they are being used for, and that not all interventions are appropriate for all areas, such as computer applications not being suitable where system capacity is lacking. Implications for practice: Healthcare professionals need to be aware of venous thromboembolism clinical practice guidelines and improve patient outcomes by using them in the hospital setting. There are a number of interventions that can improve guideline compliance, keeping in mind the barriers and adjusting practice to avoid them. Implications for research: Venous thromboembolism compliance within rural Australian hospitals has not been determined, however as inequalities have been identified in other areas of healthcare between urban and rural regions this would be a logical area to research. 131 Gay SE and Munaco S. What NPs need to know about anticoagulation therapy. Nurse Practitioner. 2012;37(10):28-34 7p. 78 Geersing GJ, Koek HL, Schouten HJ and Van Delden JJM. Diagnostic decision making in patients with suspected venous thromboembolism across hospital walls and age limits. European Geriatric Medicine. 2014;5(S38-S39. How diagnosing VTE in older patients might differ from diagnosing VTE in younger adult patients (G.J. Geersing): To correctly exclude the presence of VTE without need for further diagnostic workup, so-called diagnostic decision rules based on a weighed combination of signs and symptoms and the result of the D-dimer test have been developed. These strategies have been derived and validated in both primary and secondary care patients suspected of VTE. Notably frail older patients might benefit from such a strategy provided that it can safely rule-out VTE in a substantial proportion of them without needing to be referred for imaging examination. Yet, the accuracy of these existing clinical decision rules to rule-out VTE has never been tested in elderly populations. Geert-Jan Geersing will discuss how diagnosing VTE in older patients might differ from diagnosing VTE in younger adult patients. The predictive performance of clinical decision rules is susceptible to changes in patient populations and these rules might therefore perform worse in older patients in whom the prevalence of both VTE and co-morbidity are higher and the presentation of VTE might be more obscure. Also, the translation of rules derived in hospital setting to primary care or nursinghome setting might be problematic. In addition, current available diagnostic strategies recommend referral for further imaging examination for more than half of the patients, whereas diagnostic decision strategies that would spare higher proportions of older patients the possible hazardous referral for imaging examination might better serve their needs. Based on: Schouten HJ, Koek HL, Moons KG, van Delden JJ, Oudega R, Geersing GJ. Eur J Gen Pract. 2013 Jun; 19(2): 123-7. Validity of clinical decision rules to rule out VTE in older ambulatory patients (H.L. Koek): Dineke Koek will present the results of the "Venous thromboembolism in the elderly" study; a prospective validation study on the accuracy of clinical decision rules to exclude venous thromboembolism in frail older nursing home patients and primary care patients (mean age 80 years) with clinically suspected deep vein thrombosis or pulmonary embolism. VTE occurred in 29% of the patients primarily suspected of pulmonary embolism and in 47% of those primarily suspected of deep vein thrombosis. This prevalence was much higher than in previous studies in populations of younger adult patients (reporting a prevalence between 7% and 20%). This resulted in a higher failure rate (false negative rate) in patients who had a low score on the clinical decision rule and a normal D-dimer test (6% in our study versus below 2% in previous studies). Dineke Koek will also discuss the potency of clinical decision rules to rule in VTE in frail older patients (as opposed to the current approach of ruling out VTE). A combined rule-out and rule-in approach may enable clinicians' decision-making for up to 58% of patients without the need for further diagnostic work-up. Based on: Schouten HJ, Koek HL, Oudega R, Van Delden JJ, Moons KG, Geersing GJ. Accuracy of decision strategies in diagnosing deep vein thrombosis in frail older out-of-hospital patients a validation study. Submitted. And: Schouten HJ, Geersing GJ, Oudega R, Van Delden JJ, Moons KG, Koek HL. Accuracy of the Wells-rule for pulmonary embolism in older ambulatory patients. Submitted. The diagnostic value of the D-dimer test using either conventional or age-adjusted cut-off values in older patients with suspected VTE (H.J. Schouten): A normal D-dimer test can rule out VTE in patients with a nonhigh clinical probability according to a clinical decision rule. Since D-dimer levels increase with age, D-dimer testing is less useful to exclude VTE in older patients if the conventional cut-off value (500 mg/L) above which the test is considered abnormal is applied. As potential solution of this problem, researchers proposed to use an age-adjusted cut-off value (age.10 mg/L) in patients >50 years. In the third part of the symposium, Henrike Schouten will discuss the results of systematic review and bivariate random effects metaanalysis on this topic. We included 13 cohorts that enrolled older patients suspected of VTE in whom D-dimer testing (using both conventional and age-adjusted cut-off values) and reference testing were performed. Based on published data we reconstructed 2x2 tables, stratified by predefined age-categories and applied D-dimer cut-off value. We found that the proportion of patients with a nonhigh clinical probability (according to a clinical decision rule) in whom D-dimer testing could exclude VTE was only 12.4% in those aged more than 80 years. Therefore, D-dimer testing has limited utility in older patients when the conventional cut-off value is applied. Application of age-adjusted cut-off values increased the specificity without modifying the sensitivity which remained >97% in all age categories and would have resulted in correctly avoided imaging examinations in 30-42% of patients over 60 years with a non-high probability as compared to 1233% when the conventional cut-off value was applied. Based on: Schouten HJ, Koek HL, Oudega R, Geersing GJ, Janssen KJ, van Delden JJ, Moons KG. BMJ 2012 Jun 6; 344: e2985. And: Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA, van Delden JJ, Moons KG, Reitsma JB. BMJ. 2013 May 3; 346: f2492. Considerations in decisions to either refer foror to withhold additional diagnostic investigations in frail older patients (J.J.M. van Delden): Patients with a high risk of VTE require appropriate imaging examination to confirm or refute the diagnosis. These imaging modalities are mostly not available in primary care and nursing home settings, necessitating patients in the high-risk category to be referred to a hospital. Prior work has shown that frail older patients are vulnerable for distress and complications resulting from transitions to hospital-care. Hence, physicians might feel reluctant to refer frail elderly patients for additional investigations. Hans van Delden will set out the results of a study on physicians' considerations in their decision-making to either refer for or to withhold additional diagnostic investigations in nursing home patients with suspected VTE. We applied both quantitative and qualitative methods. In the quantitative part, patient outcomes were related to the decision to withhold diagnostic investigations. Referral for additional diagnostic investigations was withheld in four out of ten nursing home patients for whom imaging examination for suspected VTE was indicated. Patients in whom diagnostic investigations were withheld had a higher mortality rate than referred patients. For a better understanding of elderly care physicians' decisions, in-depth interviews were performed and analysed using the grounded theory approach. In their decisions to forgo diagnostic investigations, physicians incorporated the severity of symptoms and estimated prognosis of the disease in the light of the patients' chronic condition, potential benefits of diagnostic investigations and whether perfor-ming investigations agreed with pre-established management goals in advance care planning.