Correction: Thrombotic and bleeding events,mortality, and anticoagulant use among 546,656 hospitalized patients with COVID‑19 in the United States: a retrospective cohort study

Journal of Thrombosis and Thrombolysis -     

Venous thromboembolism prevention with LMWHs in medical and orthopedic surgery patients

OBJECTIVE: To discuss the role of low-molecular-weight heparins (LMWHs) in the prevention of venous thromboembolism (VTE) in medical and orthopedic surgery patients. VTE prophylaxis trials in these practice settings establishing the current use of LMWHs marketed in the US are included. An overview is also provided of VTE incidence, risk factors, and prophylaxis consensus guidelines. DATA SOURCES AND STUDY SELECTION: Clinical trials, review articles, and meta-analyses for Food and Drug Administration-approved LMWHs were identified from a MEDLINE search (1980-March 2002). Search terms included dalteparin, enoxaparin, internal medicine, low-molecular-weight heparin, orthopedic surgery, risk factors, tinzaparin, and venous thromboembolism. DATA SYNTHESIS: Consensus guidelines are useful as an initial guide to appropriate VTE prophylaxis; however, a review of the primary literature is needed to identify optimal agents, regimens, or interventions. LMWHs have demonstrated sound efficacy in VTE prevention; however, the quantity and quality of literature are not always comparable for the available agents. CONCLUSIONS: Enoxaparin has demonstrated efficacy and safety in VTE prevention in medical patients, whereas information is limited or lacking for dalteparin and tinzaparin. Total hip replacement (THR) trials have been conducted with all US-marketed LMWHs and have demonstrated the efficacy and safety of each agent. Trials specifically establishing the efficacy of an LMWH in total knee replacement surgery (TKR) have been published for enoxaparin. One combination THR and TKR trial has been published for tinzaparin. These trial outcomes have positioned the LMWHs as key alternatives to adjusted-dose warfarin for VTE prophylaxis in orthopedic surgery. Inherent differences between LMWHs prevent the extrapolation of clinical outcomes from 1 trial to another.     

Prevention of venous thromboembolism in the orthopedic surgery patient

Patients undergoing major orthopedic surgery--hip or knee arthroplasty, or hip fracture repair--are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.     

Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis?

The US Surgical Care Improvement Project (SCIP) has approved two performance measures to improve venous thromboembolism (VTE) prevention. SCIP-VTE-2 measures the proportion of surgery patients who received appropriate VTE prophylaxis within 24 h prior to surgery to 24 h after surgery. This study assesses the current rate of achievement of SCIP-VTE-2 criteria using a retrospective data set of real-world surgical patients. The Premier Perspective™ database, which contains real-world data from >400 US hospitals, was queried (January 2004–December 2006) for in-patient hospital transactional billing records of surgical patients aged ≥18 years. The primary outcome was the proportion of patients achieving SCIP-VTE-2 requirements for appropriate and timely prophylaxis as per the SCIP-VTE-2 algorithm. Of the 149,785 patients included, 56.2% received appropriate prophylaxis and 52.7% achieved the SCIP-VTE-2 performance measure for both appropriate and timely prophylaxis. To conclude, this study highlights that VTE prophylaxis currently only meets SCIP-VTE-2 requirements in approximately half of real-world surgical patients. The use of retrospective analyses such as this hospital billing data analysis may assist hospitals in measuring their current and future performance in VTE prevention.     

Hyponatremia-Associated Healthcare Burden Among US Patients Hospitalized for Cirrhosis

Introduction

Hyponatremia is a frequent comorbid condition of patients hospitalized for cirrhosis and a predictor of disease severity and mortality. This study evaluated the healthcare burden of hyponatremia among patients hospitalized for cirrhosis in the real world.

Methods

Hyponatremic (HN) patients (>-18 years of age) with cirrhosis were identified using the Premier Hospital Database (January 1, 2007 to March 31, 2010) and matched to non-HN patients with cirrhosis using a combination of exact patient characteristics and propensity score matching. Univariate and multivariate statistics were utilized to compare hospital resource utilization, cost, and 30-day hospital re-admission among patient cohorts.

Results

The study population included 21,864 subjects (HN 10,932; non-HN 10,932). The hospital length of stay (LOS) (7.63 ± 7.4 vs. 5.89 ± 6.2 days; P < 0.001), hospital cost ($13,842 ± $20,702 vs. $11,140 ± $20,562; P < 0.001), intensive care unit (ICU) LOS (4.58 ± 4.7 vs. 3.59 ± 4.4 days; P < 0.001), and ICU cost ($7,038 ± $7,781 vs. $5,360 ± $7,557; P < 0.001) were greater for the HN cohort, as was the 30-day re-admission rate (all cause: 31.1% vs. 24.8%; P < 0.001; hyponatremia related: 25.1% vs. 11.0%; P < 0.001). Multivariate analysis showed that hyponatremia was associated with a 29.5% increase in hospital LOS, a 26.6% increase in overall hospital cost, a 23.2% increase in S. ICU LOS, and a 28.6% increase in ICU cost. Additionally, hyponatremia was associated with an increased risk of 30-day hospital re-admission (all cause: odds ratio [OR] 1.37; confidence interval [CI] 1.28-1.46; P < 0.001; hyponatremia related: OR 2.68; CI 2.48-2.90; P < 0.001).

Conclusion

Hyponatremia in patients with cirrhosis is a predictor of increased hospital resource use and 30-day hospital re-admission, and represents a potential target for intervention to reduce healthcare expenditures for patients hospitalized for cirrhosis.     

Warfarin time in therapeutic range and its impact on healthcare resource utilization and costs among patients with nonvalvular atrial fibrillation

Background:

Warfarin is efficacious for reducing stroke risk among patients with nonvalvular atrial fibrillation (NVAF). However, the efficacy and safety of warfarin are influenced by its time in therapeutic range (TTR).

Objective:

To assess differences in healthcare resource utilization and costs among NVAF patients with low (<60%) and high (≥60%) warfarin TTRs in an integrated delivery network (IDN) setting.

Methods:

Patients with NVAF were identified from an electronic medical record database. Patients were required to have ≥6 international normalized prothrombin time ratio (INR) tests. NVAF patients were grouped into two cohorts: those with warfarin TTR <60% (low TTR) and those with warfarin TTR ≥60% (high TTR). Healthcare resource utilization and costs were evaluated during a 12 month follow-up period. Multivariable regressions were used to assess the impact of different warfarin TTRs on healthcare costs.

Results:

Among the study population, greater than half (54%, n?=?1595) had a low TTR, and 46% (n?=?1356) had a high TTR. Total all-cause healthcare resource utilization was higher among patients in the low TTR cohort vs. the high TTR cohort (number of encounters: 70.2 vs. 56.1, p?<?0.001). After adjusting for patient characteristics, total all-cause healthcare costs and stroke-related healthcare costs were $2398 (p?<?0.001) and $687 (p?=?0.02) higher, respectively, for patients in the low TTR cohort vs. the high TTR cohort.

Limitations:

In this retrospective study, we were only able to evaluate the association and not the causality between healthcare resource utilization and costs with the different warfarin TTRs.

Conclusion:

Many warfarin-treated NVAF patients have a low warfarin TTR. NVAF patients with low vs. patients with high warfarin TTR used healthcare resources to a greater extent, which was reflected in higher healthcare costs.