Prevention of gastrointestinal events in patients on antithrombotic therapy in the peri‐endoscopy period: Review of new evidence and recommendations from recent guidelines

Management of patients on antithrombotic therapy undergoing endoscopic procedures can be challenging. Although guidelines from major gastrointestinal endoscopy societies provide useful recommendations in this regard, data are limited concerning the bleeding risk of new complex endoscopic procedures and the management of novel anticoagulants in patients needing invasive procedures. The approach to the management of antithrombotic therapy often needs to be formulated on an individual basis, especially in patients with high thrombotic risk undergoing a high‐risk endoscopic procedure. In addition to the procedure‐related bleeding risk, endoscopists also need to consider the urgency of the endoscopic procedure, the thromboembolic risk of the patient if antithrombotic therapy is temporarily withheld, and the timing of discontinuation/resumption of antithrombotic therapy in the decision‐making process. Diagnostic endoscopic procedures with or without biopsy can often be done without interruption of antithrombotic therapy. If possible, elective procedures with high bleeding risk should be delayed in patients on antithrombotic therapy for conditions with high thrombotic risk. If high‐risk procedures cannot be delayed in these patients, thienopyridines, traditional and novel anticoagulants are usually withheld, whereas aspirin withdrawal is decided on a case by case basis. In patients with high thrombotic risk, communication with the prescribing clinician before proceeding to procedures with high bleeding risk is particularly important in optimizing the peri‐procedural management plan of antithrombotic therapy.     

Balancing the risks of stroke and upper gastrointestinal tract bleeding in older patients with atrial fibrillation

OBJECTIVE: To determine how factors that increase the risk of major upper gastrointestinal (GI) tract hemorrhage (recent upper GI tract bleeding or concurrent use of nonsteroidal anti-inflammatory drugs) influence the choice of antithrombotic therapy in older patients (those > or = 65 years) with atrial fibrillation. METHODS: For older patients with atrial fibrillation and no other contraindications to antithrombotic therapy, a Markov decision-analytic model was used to determine the preferred treatment strategy (no antithrombotic therapy, long-term aspirin use, or long-term warfarin sodium use) based on their risk of major upper GI tract hemorrhage. Input data were obtained by a systematic review of MEDLINE. Outcomes were expressed as quality-adjusted life-years (QALYs). RESULTS: For 65-year-old patients with average risks of stroke and upper GI tract bleeding, warfarin therapy was associated with 12.1 QALYs per patient; aspirin therapy, 10.8 QALYs; and no antithrombotic therapy, 10.1 QALYs. For persons with significantly higher risks of upper GI tract bleeding and/or lower risks of stroke, warfarin was no longer clearly the optimal antithrombotic therapy (eg, for 80-year-old persons with a baseline risk of stroke of 4.3% per year who were concurrently taking a conventional nonsteroidal anti-inflammatory drug: warfarin, 7.44 QALYs; aspirin, 7.39 QALYs; and no treatment, 7.21 QALYs). CONCLUSIONS: For older patients with atrial fibrillation and factors that place them at a higher than average risk of upper GI tract bleeding, the optimal choice of antithrombotic therapy to prevent stroke can vary according to the magnitude of this risk. Based on the risks of stroke and upper GI tract bleeding, clinicians can use the treatment recommendations of this study to provide rational stroke prevention therapy for older patients with atrial fibrillation.     

The effect of a geriatric evaluation on treatment decisions for older patients with colorectal cancer

Background

Treating elderly colorectal cancer patients can be challenging. It is very important to carefully weigh the risks and benefits of potential treatments in individual patients. This treatment decision making can be guided by geriatric consultation. Our aim was to assess the effect of a geriatric evaluation on treatment decisions for older patients with colorectal cancer.

Methods

Colorectal cancer patients who were referred for a geriatric consultation between 2013 and 2015 in three Dutch teaching hospitals were included in a prospective database. The outcome of geriatric assessment, non-oncological interventions and geriatricians’ treatment recommendations were evaluated.

Results

The total number of included referrals was 168. The median age was 81 years (range 60–94). Most patients (71%) had colon cancer and 49% had tumour stage III disease. The reason for geriatric consultation was uncertainty regarding the optimal oncologic treatment in 139 patients (83%). Overall 93% of patients suffered from geriatric impairments; non-oncological interventions that followed after geriatric consultation was mostly aimed at malnutrition. The geriatrician recommended the ‘more intensive treatment’ option in 69% and the ‘less intensive treatment’ option in 31% of which 63% ‘supportive care only’.

Conclusion

Geriatric consultation can be useful in treatment decision making in elderly patients with colorectal cancer. It may lead to changes in the treatment plan for individual cases and may result in an additional optimisation of patient’s health status prior to treatment.

     

How does overeaters anonymous help its members? A qualitative analysis

Overeaters Anonymous (OA) is a 12‐step, self‐help group for individuals who perceive themselves to have problems with compulsive overeating. Despite the popularity of OA and the frequent use of addictions‐based treatments for eating disorders, little is known about how OA is helpful. The purpose of this qualitative study was to explore members' experiences with and perceptions of OA. We conducted three focus groups with self‐selected members of OA (N = 20). We present three primary themes that emerged from the analysis of the focus groups' discussions, which emphasize why individuals entered OA, OA's ‘tools’, and how individuals perceived OA to ‘work’. Overall, although participants agreed OA was helpful to them, there was no consensus regarding how OA ‘works’. Copyright © 2009 John Wiley & Sons, Ltd and Eating Disorders Association.     

Physicians' Views on the Importance of Patient Preferences in Surrogate Decision‐Making

OBJECTIVES: To explore the degree to which physicians report reliance on patient preferences when making medical decisions for hospitalized patients lacking decisional capacity. DESIGN: Cross‐sectional survey. SETTING: One academic and two community hospitals in a single metropolitan area. PARTICIPANTS: Two hundred eighty‐one physicians who recently cared for hospitalized adults. MEASUREMENTS: A self‐administered survey addressing physicians' beliefs about ethical principles guiding surrogate decision‐making and physicians' recent decision‐making experiences. RESULTS: Overall, 72.6% of physicians identified a standard related to patient preferences as the most important ethical standard for surrogate decision‐making (61.2% identified advanced directives and 11.4% substituted judgment). Of the 73.3% of physicians who reported recently making a surrogate decision, 81.8% reported that patient preferences were highly important in decision‐making, although only 29.4% reported that patient preference was the most important factor in the decision. Physicians were significantly more likely to base decisions on patient preferences when the patient was in the intensive care unit (odds ratio (OR)=2.92, 95% confidence interval (CI)=1.15–7.45) and less likely when the patient was older (OR=0.76 for each decade of age, 95% CI=0.58–0.99). The presence of a living will, prior discussions with the patient, and the physicians' beliefs about ethical guidelines did not significantly predict the physicians' reliance on patient preferences. CONCLUSION: Although a majority of physicians identified patient preferences as the most important general ethical guideline for surrogate decision‐making, they relied on a variety of factors when making treatment decisions for a patient lacking decisional capacity.     

When Frail Individuals or Their Families Request Nonindicated Interventions: Usefulness of the Four‐Box Ethical Approach

In the age of person‐centered care, there is an emphasis on promoting patient autonomy and surrogate decision maker authority in making treatment decisions that are aligned with the patient's priorities and values. As technological advances offer multiple clinical options with various levels and types of risks and benefits, person‐centered clinical practice encourages the incorporation of patients' and families' heterogeneous experiences into decisions regarding illness management. In caring for frail elderly adults, clinicians are sometimes faced with situations in which individuals and their surrogate decision‐makers request a treatment that the clinicians feel is clinically inappropriate. This article provides a case example of a frail older adult with advanced chronic kidney disease who requests dialysis despite the advice of his nephrologist to pursue conservative management. The four‐box approach, which provides clinicians with a structured ethical framework to facilitate informed and ethically justified treatment decisions, is then introduced. By considering the patient's medical indications, preferences, quality of life, and contextual factors, how each consideration plays a unique yet equally important role in informing clinically responsible and person‐centered care is illustrated.     

A clinical decision aid for the selection of antithrombotic therapy for the prevention of stroke due to atrial fibrillation

Aims The availability of new antithrombotic agents, each with a unique efficacy and bleeding profile, has introduced a considerable amount of clinical uncertainty with physicians. We have developed a clinical decision aid in order to assist clinicians in determining an optimal antithrombotic regime for the prevention of stroke in patients who are newly diagnosed with non-valvular atrial fibrillation. Methods and results The CHA(2)DS(2)-VASc and HAS-BLED scoring systems were used to assess patients' baseline risks of stroke and major bleeding, respectively. The relative risks of stroke and major bleeding for each antithrombotic agent were then used to identify the agent associated with the lowest net risk. Individual patient factors such as the treatment threshold, bleeding ratio, and cost threshold modified the recommendations in order to generate a final recommendation. By considering both patient factors and clinical research concurrently, this clinical decision aid is able to provide specific advice to clinicians regarding an optimal stroke prevention strategy. The resulting treatment recommendation tables are consistent with the recommendations of the European Society of Cardiology and Canadian Cardiovascular Society Guidelines, which can be incorporated into either a paper-based or electronic format to allow clinicians to have decision support at the point of care. Conclusion The use of a clinical decision aid that considers both patient factors and evidence-based medicine will serve to bridge the knowledge gap and provide practical guidance to clinicians in the prevention of stroke due to atrial fibrillation.     

AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision‐making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non‐traditional surrogates) and a team‐based effort to ascertain the unbefriended older adult's preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state‐to‐state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including “adult orphans,” at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.     

The impact of age on antithrombotic use in elderly patients with non‐valvular atrial fibrillation

Aim of study: To investigate the use of antithrombotic therapy in elderly patients with atrial fibrillation (AF). Methods: Data were collected retrospectively from the medical records of 262 AF patients >65 years, who were admitted to a Sydney teaching hospital over a 12‐month period. Results: Overall, 202 (79%) patients were discharged on some antithrombotic therapy. Patients <80 years were as likely to receive antithrombotic therapy as those <80 years (75.8% versus 81.9%, P=0.23), but a significantly lower proportion received warfarin than did those <80 years (25.5% versus 61.5%, P < 0.0001). Definite contraindications to anticoagulation were a significant influence on antithrombotic agent selection (P=0.04), but multivariate analysis indicated that ‘old age’ was the largest contributing factor: patients >80 years were 5.46 times more likely to receive aspirin in preference to warfarin than their younger counterparts (P<0.0001). Conclusion: Warfarin is being withheld in AF patients ≥80 years for reasons other than recognised contraindications and is, therefore, potentially underutilised in the target elderly population. Further studies are necessary to determine whether this is appropriate.     

Antithrombotic therapy in atrial fibrillation and additional stroke/embolism risk factors. CORSurvey Study]

OBJECTIVES: To evaluate 1) how many patients with atrial fibrillation (AF) and heart failure were discharged from Austrian hospitals with antithrombotic therapy, 2) if the presence of risk factors for stroke/embolism (age > 65 years, arterial hypertension, diabetes, and previous stroke) influence the choice of antithrombotic therapy and if the presence of contraindications for oral anticoagulation (dementia, alcohol abuse) influence the choice of antithrombotic therapy, and 3) if there are differences among the types of departments in the use of antithrombotic therapy. PATIENTS: Included were 1566 patients (841 female, 725 male, mean age 76 years) with AF and heart failure. METHODS: At discharge, a questionnaire was completed including risk factors, contraindications for antithrombotic therapy, and antithrombotic medication. RESULTS: Oral anticoagulants (OAC) had 26% of the cases, acetyl salicylic acid (ASA) 31%, a combination of OAC and ASA 2%, and no antithrombotic therapy 41%. The risk factors age > 65 years, arterial hypertension, diabetes, and previous stroke did not influence the choice of antithrombotic therapy. Dementia but not alcohol abuse influenced the choice against OAC. The rate of OAC was higher in cardiological or cardiovascular rehabilitation clinics than in other departments. CONCLUSION: The results of this survey show that in medical practice the recommendations regarding antithrombotic therapy in atrial fibrillation are rarely considered, especially when additional risk factors are present.     

Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls

OBJECTIVE: To determine whether the risk of falling (with a possible increased chance of subdural hematoma) should influence the choice of antithrombotic therapy in elderly patients with atrial fibrillation. DESIGN: A Markov decision analytic model was used to determine the preferred treatment strategy (no antithrombotic therapy, long-term aspirin use, or long-term warfarin use) for patients with atrial fibrillation who are 65 years of age and older, are at risk for falling, and have no other contraindications to antithrombotic therapy. Input data were obtained by systematic review of MEDLINE. Outcomes were expressed as quality-adjusted life-years. RESULTS: For patients with average risks of stroke and falling, warfarin therapy was associated with 12.90 quality-adjusted life-years per patient; aspirin therapy, 11.17 quality-adjusted life-years; and no antithrombotic therapy, 10.15 quality-adjusted life-years. Sensitivity analysis demonstrated that, regardless of the patients' age or baseline risk of stroke, the risk of falling was not an important factor in determining their optimal antithrombotic therapy. CONCLUSIONS: For elderly patients with atrial fibrillation, the choice of optimal therapy to prevent stroke depends on many clinical factors, especially their baseline risk of stroke. However, patients' propensity to fall is not an important factor in this decision.     

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Objectives

To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia.

Design

Multicenter, mixed‐mode, anonymous questionnaire.

Setting

Three tertiary and four community hospitals in New York.

Participants

Internal medicine physicians (N = 168).

Measurements

Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia.

Results

Ninety‐nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision‐making process; 38% were unsure whether the ABIM/AGSChoosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGSChoosing Wisely recommendations (71% vs 28%, P < .001). Fifty‐two percent felt in control of the PEG placement decision, and 27% expressed concerns about potential litigation. The most common factor influencing physicians was patient or decision‐maker request (70%); 63% stated that families request PEG placement even when physician would not recommend it. Only 4% of the physicians would choose to have a PEG tube if they had advanced dementia.

Conclusion

Despite the scientific evidence supporting the ABIM/AGSChoosing Wisely recommendations against the use of PEG tubes in individuals with advanced dementia, numerous incentives for placement complicate the decision for PEG placement. In today's healthcare environment, it is incumbent upon healthcare practitioners to be aware of the available evidence and to provide leadership to guide this complex decision‐making process to promote true person‐centered care.     

Decision‐Making Regarding Mammography Screening for Older Women

The population is aging, and breast cancer incidence increases with age, peaking between the ages of 75 and 79. However, it is not known whether mammography screening helps women aged 75 and older live longer because they have not been included in randomized controlled trials evaluating mammography screening. Guidelines recommend that older women with less than a 10‐year life expectancy not be screened because it takes approximately 10 years before a screen‐detected breast cancer may affect an older woman's survival. Guidelines recommend that clinicians discuss the benefits and risks of screening with women aged 75 and older with a life expectancy of 10 years or longer to help them elicit their values and preferences. It is estimated that two of 1,000 women who continue to be screened every other year from age 70 to 79 may avoid breast cancer death, but 12% to 27% of these women will experience a false‐positive test, and 10% to 20% of women who experience a false‐positive test will undergo a breast biopsy. In addition, approximately 30% of screen‐detected cancers would not otherwise have shown up in an older woman's lifetime, yet nearly all older women undergo treatment for these breast cancers, and the risks of treatment increase with age. To inform decision‐making, tools are available to estimate life expectancy and to educate older women about the benefits and harms of mammography screening. Guides are also available to help clinicians discuss stopping screening with older women with less than a 10‐year life expectancy. Ideally, screening decisions would consider an older woman's life expectancy, breast cancer risk, and her values and preferences.     

Asian Organization for Crohn's and Colitis and Asian Pacific Association of Gastroenterology consensus on tuberculosis infection in patients with inflammatory bowel disease receiving anti‐tumor necrosis factor treatment. Part 1: Risk assessment

Because anti‐tumor necrosis factor (anti‐TNF) therapy has become increasingly popular in many Asian countries, the risk of developing active tuberculosis (TB) among anti‐TNF users may raise serious health problems in this region. Thus, the Asian Organization for Crohn's and Colitis and the Asian Pacific Association of Gastroenterology have developed a set of consensus statements about risk assessment, detection, and prevention of latent TB infection and management of active TB infection in patients with inflammatory bowel disease (IBD) receiving anti‐TNF treatment. Twenty‐three consensus statements were initially drafted and then discussed by the committee members. The quality of evidence and the strength of recommendations were assessed by using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Web‐based consensus voting was performed by 211 IBD specialists from nine Asian countries concerning each statement. A consensus statement was accepted if at least 75% of the participants agreed. Part 1 of the statements comprised two parts: (i) risk of TB infection during anti‐TNF therapy and (ii) screening for TB infection prior to commencing anti‐TNF therapy. These consensus statements will help clinicians optimize patient outcomes by reducing the morbidity and mortality related to TB infections in patients with IBD receiving anti‐TNF treatment.     

Perioperative management of anticoagulation: guidelines translated for the clinician

The perioperative management of patients taking vitamin K antagonists (VKAs) is an evolving area of medicine and poses significant challenges for health care providers. It has been estimated that this issue affects approximately 250,000 patients annually, and the number of patients requiring chronic anticoagulation continues to increase. The lack of evidence, along with the wide variety of clinical scenarios, requires complex decision making on the part of clinicians. In general, when a patient on chronic anticoagulation requires a planned procedure, the clinician must assess the risk of perioperative thrombotic events and the risk of perioperative bleeding complications and weigh those risks in determining the safest perioperative strategy. We aimed to summarize and provide our opinion about the recommendations from the recent 8th edition of the American College of Chest Physicians (ACCP) guidelines for the perioperative management of antithrombotic therapy.     

Developing a two‐sided intervention to facilitate shared decision‐making in haemophilia: decision boxes for clinicians and patient decision aids for patients

People with haemophilia face many treatment decisions, which are largely informed by evidence from observational studies. Without evidence‐based ‘best’ treatment options, patient preferences play a large role in decisions regarding therapy. The shared decision‐making (SDM) process allows patients and health care providers to make decisions collaboratively based on available evidence, and patient preferences. Decision tools can help the SDM process. The objective of this project was to develop two‐sided decision tools, decision boxes for physicians and patient decision aids for patients, to facilitate SDM for treatment decisions in haemophilia. Methods. Development of the decision tools comprised three phases: topic selection, prototype development and usability testing with targeted end‐users. Topics were selected using a Delphi survey. Tool prototypes were based on a previously validated framework and were informed by systematic literature reviews. Patients, through focus groups, and physicians, through interviews, reviewed the prototypes iteratively for comprehensibility and usability. Results. The chosen topics were: (i) prophylactic treatment: when to start and dosing, (ii) choosing factor source and (iii) immunotolerance induction: when to start and dosing. Intended end users (both health care providers and haemophilia patients and caregivers) were engaged in the development process. Overall perception of the decision tools was positive, and the purpose of using the tools was well received. Conclusions. This study demonstrates the feasibility of developing decision tools for haemophilia treatment decisions. It also provides anecdotal evidence of positive perceptions of such tools. Future directions include assessment of the tools’ practical value and impact on clinical practice.     

Revision of the severity rating and classification of hospital-acquired pneumonia in the Japanese Respiratory Society guidelines

Background and objective: Based on the results of a multicentre collaborative survey of hospital‐acquired pneumonia (HAP) conducted in Japan, the severity rating and classification of pneumonia in the Japanese Respiratory Society guidelines for management of HAP were examined. Methods: Parameters for the severity classification were selected from the factors associated with prognosis in the HAP survey and in other previous reports. Depending on the presence of the parameters listed below, patients with HAP were stratified into those with high, moderate or low‐risk. The high‐risk group was defined as patients with three or more of the following risk factors: ‘malignant tumour or immunocompromised status’, ‘impaired consciousness’, ‘requiring fraction of inspired oxygen (FiO₂) >35% to maintain SaO₂ >90%’, ‘man aged 70 years or older, or woman aged 75 years or older’ and ‘oliguria or dehydration.’ The moderate‐risk group was defined as patients with any of the secondary risk factors as follows: ‘CRP ≥ 200 mg/L’ and ‘extent of infiltration on CXR covers at least 2/3 of one lung’. The low‐risk group was defined as all other patients. Results: Application of this classification scheme to the patients enrolled in the HAP survey revealed a mortality rate of 40.8% (98/240) in the high‐risk group, which was significantly higher than the mortality rates in the moderate and low‐risk groups: 24.9% (69/277) and 12.1% (101/834), respectively. Conclusion: These results indicate that it is possible to classify patients using these parameters as prognostic indicators.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Prognosis in pulmonary embolism

Acute pulmonary embolism has a wide prognostic spectrum, ranging from sudden death within minutes of a thromboembolic episode to a benign treatable condition associated with a stable clinical course and no long-term sequelae. In patients who survive an initial thromboembolic episode and receive antithrombotic therapy, the clinical course can be complicated by recurrent nonfatal venous thromboembolism, fatal pulmonary embolism, the postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. Identifying which patients are at increased risk of experiencing these sequelae is important in decision making relating to the aggressiveness of initial antithrombotic therapy, the duration of antithrombotic therapy, and the frequency of clinical surveillance. In addition, this information may be helpful to clinicians in discussing disease prognosis with patients. The objectives of this review are to provide reasonable estimates of the risks of recurrent nonfatal venous thromboembolism, fatal pulmonary embolism, the postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension in patients with treated pulmonary embolism, and to identify risk factors for these sequelae.