Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients

The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis.

Purpose

To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice.

Data sources

A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS.

Study selection

Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review.

Data synthesis

Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients ≥40 years-old with decreased mobility, and ≥1 RFs should receive chemoprophylaxis with heparin, provided they don’t have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6–14 days.

Conclusions

A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients.     

Limitations and plausibility of the Pliocene lignite hypothesis in explaining the etiology of Balkan endemic nephropathy

Background:

Balkan endemic nephropathy (BEN) is a chronic, tubulointerstitial renal disease often accompanied by urothelial cancer that has a lethality of nearly 100%.

Introduction:

One of the many factors that have been proposed to play an etiological role in BEN is exposure to organic compounds from Pliocene lignite coal deposits via the drinking water in endemic areas.

Objectives:

The objective of this study was to systematically evaluate the role of the tenets of the Pliocene lignite hypothesis in the etiology of BEN in order to provide an improved understanding of the hypothesis for colleagues and patients alike.

Methods:

A comprehensive compilation of the possible limitations of the hypothesis, with each limitation addressed in turn is presented.

Results:

The Pliocene lignite hypothesis can best account for, is consistent with, or has the potential to explain the evidence associated with the myriad of factors related to BEN.

Conclusions:

Residents of endemic areas are exposed to complex mixtures containing hundreds of organic compounds at varying doses and their potentially more toxic (including nephrotoxic) and/or carcinogenic metabolites; however, a multifactorial etiology of BEN appears most likely.     

Epidemiology and Predictors of End-stage Renal Disease in Taiwanese Children With Idiopathic Nephrotic Syndrome

Background

The incidence of idiopathic nephrotic syndrome (INS) varies among countries, with Asia reporting a higher incidence in comparison with Western countries. We investigated the epidemiologic features of INS and attempted to identify factors that predispose individuals to develop end-stage renal disease (ESRD).

Methods

Claims data from the Taiwanese National Health Insurance program from 1996 to 2008 were used to investigate the epidemiologic features and clinical variables of INS (International Classification of Diseases, Ninth Revision, Clinical Modification code, 581) in children younger than 18 years.

Results

We enrolled 4083 children (male-female ratio, 1.91:1). During the 13 years of observation, annual incidence decreased from 9.91 to 3.36 per 100 000 children. Annual number of hospital admissions progressively decreased during the first 3 years after diagnosis. At 3.14 ± 2.77 years after INS onset, ESRD had developed in 145 (3.6%) children. Independent predictors of ESRD included older age at onset, acute renal failure (ARF), hypertensive encephalopathy, and a histologic subtype with focal segmental glomerulosclerosis (FSGS).

Conclusions

Pediatric INS in Taiwan was more frequent in boys. Unlike India, the current incidence of pediatric INS in Taiwan is very similar to that reported in Western studies. Older age at disease onset, ARF, hypertensive encephalopathy, and FSGS on biopsy are important predictors of poor renal outcome.Key words: idiopathic nephrotic syndrome, long-term outcome, children, end-stage renal disease     

PEER REVIEWED: Targeting Diabetes Preventive Care Programs: Insights From the 2001 Behavioral Risk Factor Surveillance Survey

Introduction

Many individuals with diabetes do not receive flu or pneumonia vaccinations or dilated eye exams, despite the documented efficacy of these practices. Understanding the individual factors associated with not receiving recommended vaccinations and exams is essential to developing effective targeted promotional programs.

Methods

Data from the 2001 Behavioral Risk Factor Surveillance Survey were analyzed to identify predictors of failure to report flu and pneumonia vaccinations and dilated eye exams. Key predictors included indicators of disease severity, access to care, and demographic characteristics.

Results

Significant factors varied by vaccination. For all 3 practices, failure to receive was associated with being younger, being a member of an ethnic minority group, having had no diabetes education, not taking insulin, and engaging in fewer prevention practices requiring physician contact. Other salient characteristics included having no health insurance, having less education, and reporting good general health.

Conclusion

Promotional programs should be tailored for younger, minority patients, and those messages should encourage preventive care despite general good health or less severe disease. Indirect methods of promotion may include participation in diabetes education programs and regular contact with physicians. Additionally, health care professionals may be appropriate target groups for preventive care campaigns.     

Estimation of disease incidence in claims data dependent on the length of follow-up: a methodological approach

Objective

To analyze the impact of the length of disease-free intervals on incidence estimation.

Data Source

Statutory health insurance sample in Germany.

Study Design

Overestimation of the incidence in the first quarter of 2008 for three selected diseases, diabetes mellitus, colorectal cancer, and heart failure, depending on different lengths of preceding disease-free intervals.

Data Collection/Extraction Methods

Continuously insured from 2000 until 2008 ≥18 years (N = 144,907).

Principal Findings

Compared with an 8-year disease-free period, incidence overestimations for diabetes, colorectal cancer, and heart failure were 40, 23, and 43 percent defining a 1-year, and 5, 9, and 5 percent defining a 5-year disease-free period, respectively.

Conclusions

Depending on the specific disease, caution has to be taken while using short disease-free periods because incidence estimates may be extremely overestimated.     

Community Factors and Hospital Readmission Rates

Objective

To examine the relationship between community factors and hospital readmission rates.

Data Sources/Study Setting

We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets.

Study Design

We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate.

Data Collection/Extraction Methods

Not applicable.

Principal Findings

The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties.

Conclusions

Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.     

Coordinated hospital-home care for kidney patients on hemodialysis from the perspective of nursing personnel

OBJECTIVE:

To examine, from the nursing perspective, the needs and challenges of coordinated hospital-home care for renal patients on hemodialysis.

METHODS:

A qualitative analysis was conducted with an ethnographic approach in a hemodialysis unit in San Luis Potosi, Mexico. Semistructured interviews were conducted with nine nurses, selected by purposeful sampling. Structured content analysis was used.

RESULTS:

Nurses recounted the needs and challenges involved in caring for renal patients. They also identified barriers that limit coordinated patient care in the hospital and the home, mainly the work overload at the hemodialysis unit and the lack of a systematic strategy for education and lifelong guidance to patients, their families and caregivers.

CONCLUSIONS:

This study shows the importance and necessity of establishing a strategy that goes beyond conventional guidance provided to caregivers of renal patients, integrating them into the multidisciplinary group of health professionals that provide care for these patients in the hospital to establish coordinated hospital-home care that increases therapeutic adherence, treatment substitution effectiveness and patient quality of life.     

Can Claims-Based Data Be Used to Recruit Black and Hispanic Subjects into Clinical Trials?

Objective

Evaluate the accuracy of an algorithm at identifying ethnic minorities from administrative claims for enrollment into a clinical trial.

Data Sources/Study Setting

Claims data from a health benefits company.

Study Design

We compared results of a three-step algorithm to self-reported race/ethnicity.

Data Collection/Extraction Methods

Using the algorithm, we identified subjects with high probability of being minority and ascertained self-reported race/ethnicity.

Principal Findings

We identified 164 subjects as likely minority based on our algorithm. Of these, 94 completed the survey and 87 identified themselves as black or Hispanic. The positive predictive value of the algorithm was 93 percent (CI: 85–97).

Conclusions

Claims data can be used to efficiently identify minorities for participation in clinical trials.     

An Algorithm That Identifies Coronary and Heart Failure Events In The Electronic Health Record

Objective

The objective of this project was to identify criteria that accurately categorize acute coronary and heart failure events exclusively with electronic health record data so that the medical record can be used for surveillance without manual record review.

Introduction

Surveillance to track the incidence, prevalence and treatment of disease is a fundamental task of public health. The advent of universal health care coverage in the United States and electronic health records could make the medical record a valuable disease surveillance tool. This can only happen, however, if the necessary data can be extracted from the medical record without manual review.

Methods

We serially compared 3 different computer algorithms to manual record review. The first two algorithms relied on ICD9CM codes, troponin levels, ECG data and echocardiographic data. The 3rd algorithm relied on a very detailed coding system, IMO statements, troponin levels and echocardiographic data.

Results

Cohen’s Kappa for the initial algorithm was 0.47 (95%CI 0.41–0.54). Cohen’s Kappa was 0.61 (95%CI 0.55–0.68) for the second algorithm. Cohen’s Kappa for the third algorithm was 0.99 (95%CI 0.98–1.00).

Conclusions

We conclude that electronic medical record data are sufficient to categorize coronary heart disease and heart failure events without manual record review. However, only moderate agreement with medical record review can be achieved when the classification is based on 4-digit ICD9CM codes because ICD9CM 410.9 includes myocardial infarction with ST elevation (STEMI) and myocardial infarction without ST elevation (nSTEMI). Nearly perfect agreement can be achieved using IMO statements, a more detailed coding system that tracks to ICD9, ICD10 and SnoMED-CT. IMO statements are available in many electronic medical record systems.     

Factors Affecting Receipt of Expensive Cancer Treatments and Mortality: Evidence from Stem Cell Transplantation for Leukemia and Lymphoma

Objective

To identify factors that affect whether patients diagnosed with either leukemia or lymphoma receive a stem cell transplant and secondly if receipt of stem cell transplantation is linked to improved survival.

Data

California inpatient discharge records (2002–2003) for patients with either leukemia or lymphoma linked with vital statistics death records (2002–2005).

Study Design

Bivariate Probit treatment effects model that accounts for both the type of treatment received and survival while controlling for nonrandom selection due to unobservable factors.

Principal Findings

Having private insurance coverage and residence in a well-educated county increased the chances a patient with either disease received HSCT. Increasing age and travel distance to the nearest transplant hospital had the opposite effect. Receipt of HSCT had a significant impact on mortality. We found the probability of death was 4.3 percentage points higher for leukemia patients who did NOT have HSCT. Receipt of HSCT reduced the chances of dying by almost 50 percent. The likelihood of death among lymphoma patients who underwent HSCT was almost 5 percentage points lower, a 70 percent reduction in the probability of death.

Conclusions

The findings raise concern about access to expensive, but highly effective cancer treatments for patients with certain hematologic malignancies.     

Climate Variability,Social and Environmental Factors,and Ross River Virus Transmission: Research Development and Future Research Needs

Background

Arbovirus diseases have emerged as a global public health concern. However, the impact of climatic, social, and environmental variability on the transmission of arbovirus diseases remains to be determined.

Objective

Our goal for this study was to provide an overview of research development and future research directions about the interrelationship between climate variability, social and environmental factors, and the transmission of Ross River virus (RRV), the most common and widespread arbovirus disease in Australia.

Methods

We conducted a systematic literature search on climatic, social, and environmental factors and RRV disease. Potentially relevant studies were identified from a series of electronic searches.

Results

The body of evidence revealed that the transmission cycles of RRV disease appear to be sensitive to climate and tidal variability. Rainfall, temperature, and high tides were among major determinants of the transmission of RRV disease at the macro level. However, the nature and magnitude of the interrelationship between climate variability, mosquito density, and the transmission of RRV disease varied with geographic area and socioenvironmental condition. Projected anthropogenic global climatic change may result in an increase in RRV infections, and the key determinants of RRV transmission we have identified here may be useful in the development of an early warning system.

Conclusions

The analysis indicates that there is a complex relationship between climate variability, social and environmental factors, and RRV transmission. Different strategies may be needed for the control and prevention of RRV disease at different levels. These research findings could be used as an additional tool to support decision making in disease control/surveillance and risk management.     

Lower limb amputation in England: prevalence,regional variation and relationship with revascularisation,deprivation and risk factors. A retrospective review of hospital data

Objective

We describe the prevalence of major lower limb amputation across England and its relationship with revascularisation, patient demography and disease risk factors.

Design

Retrospective cohort study.

Setting

England 1 April 2003 to 31 March 2009.

Participants

Patients aged 50–84 years.

Main outcome measures

Age standardised prevalence rates were calculated using Hospital Episode Statistics as the numerator with census data as the denominator. The outcome measure ‘amputation with revascularisation’ was created if an amputation could be linked with a revascularisation. Logistic regression determined the odds of having an amputation with a revascularisation across England. Regression was performed unadjusted and repeated after controlling for demographic (age, sex, social deprivation) and disease risk factors (diabetes, hypertension, coronary heart disease, cerebrovascular disease, smoking).

Results

There were 25,312 amputations and 136,215 revascularisations, and 7543 cases were linked. The prevalence rate per 100,000 (95% confidence intervals) for amputation was 26.3 (26.0–26.6) with rates significantly higher in Northern England (North: 31.7; 31.0–32.3, Midlands: 26.0; 25.3–26.7, South: 23.1; 22.6–23.5). The revascularisation rate was 141.6 (140.8–142.3) with significantly higher rates again in Northern England (North: 182.1; 180.5–183.7, Midlands: 121.3; 119.8–122.9, South 124.9; 123.9–125.8). The odds of having an amputation with a revascularisation remained significantly higher in the North (OR 1.22; 1.13–1.33) even after controlling demographic and disease risk factors.

Conclusions

There is a North–South divide in England for both major lower limb amputation and revascularisation. The higher odds of having an amputation with a revascularisation in the North were not fully explained by greater levels of deprivation or disease risk factors.     

Listening to food workers: Factors that impact proper health and hygiene practice in food service

Background

Foodborne disease is a significant problem worldwide. Research exploring sources of outbreaks indicates a pronounced role for food workers'' improper health and hygiene practice.

Objective

To investigate food workers'' perceptions of factors that impact proper food safety practice.

Method

Interviews with food service workers in Baltimore, MD, USA discussing food safety practices and factors that impact implementation in the workplace. A social ecological model organizes multiple levels of influence on health and hygiene behavior.

Results

Issues raised by interviewees include factors across the five levels of the social ecological model, and confirm findings from previous work. Interviews also reveal many factors not highlighted in prior work, including issues with food service policies and procedures, working conditions (e.g., pay and benefits), community resources, and state and federal policies.

Conclusion

Food safety interventions should adopt an ecological orientation that accounts for factors at multiple levels, including workers'' social and structural context, that impact food safety practice.     

Organizational Status of Dialysis Facilities and Patient Outcome: Does Higher Injectable Medication Use Mediate Increased Mortality?

Objective

Examine the mediating effect of injectable drugs in the relationship between dialysis facility organizational status and patient mortality.

Study Setting

Medicare dialysis population.

Study Design

Data from the U.S. Renal Data System (USRDS) were used to identify 3,884 freestanding dialysis facilities and 37,942 Medicare patients incident to end-stage renal disease (ESRD) in 2006. The role of injectable medications was evaluated during a 2-year follow-up period by mediational analyses using mixed-effect regression models.

Data Collection

USRDS data were matched with Dialysis Facility Report data from Centers for Medicare and Medicaid Services (CMS) and census data.

Principal Findings

There was a strong association found between organizational status and use of injectable drugs. Large for-profit chains used significantly higher injectable medications compared with nonprofit chains and independent facilities. However, the relationship between facility organizational status and patient mortality was not found to be mediated through the higher use of injectable drugs.

Conclusions

Large for-profit chain facilities administered higher IV epoetin, iron, and vitamin D dosages, but this did not result in improved survival. Given the associated costs and lack of a survival benefit, the overuse of injectable medications among the U.S. dialysis patients will likely end under the recent bundling of injectable medications without jeopardizing patient outcomes.     

Renal function, bisphenol A, and alkylphenols: results from the National Health and Nutrition Examination Survey (NHANES 2003-2006)

Background

Urinary excretion of bisphenol A (BPA) and alkylphenols (APs) was used as a biomarker in most previous studies, but no study has investigated whether urinary excretion of these environmental phenols differed by renal function.

Objective

We estimated the association between renal function and urinary excretion of BPA and APs.

Methods

Analyses were conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006. Renal function was measured as estimated glomerular filtration rate (eGFR) calculated by the Modification of Diet in Renal Disease (MDRD) Study equation and by the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Regression models were used to calculate geometric means of urinary BPA and APs excretion by eGFR category (≥ 90, 60–90, < 60 mL/min/m²) after adjusting for potential confounding factors.

Results

When we used the MDRD Study equation, participants without known renal disease (n = 2,573), 58.2% (n = 1,499) had mildly decreased renal function or undiagnosed chronic kidney disease. The adjusted geometric means for urinary BPA excretion decreased with decreasing levels of eGFR (p for trend = 0.04). The associations appeared primarily in females (p for trend = 0.03). Urinary triclosan excretion decreased with decreasing levels of eGFR (p for trend < 0.01) for both males and females, and the association primarily appeared in participants < 65 years of age. The association between BPA and eGFR was nonsignificant when we used the CKD-EPI equation.

Conclusions

Urinary excretion of triclosan, and possibly BPA, decreased with decreasing renal function. The associations might differ by age or sex. Further studies are necessary to replicate our results and understand the mechanism.     

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals,Uganda

Setting:

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

Objective:

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

Design:

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

Results:

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

Conclusion:

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.     

End-stage Renal Disease in Taiwan: A Case–Control Study

Background

Taiwan has the highest incidence of end-stage renal disease (ESRD) in the world. The epidemiologic features of ESRD, however, have not been investigated. In this case–control study, we evaluated the risk of ESRD associated with a number of putative risk factors.

Methods

We studied 200 patients among whom ESRD had been newly diagnosed between 1 January 2005 and 31 December 2005; 200 controls were selected from among relatives of patients treated in the general surgery unit. Using a structured questionnaire, we collected information related to socioeconomic factors, history of disease, regular blood or urine screening, lifestyle, environmental exposure, consumption of vitamin supplements, and regular drug use at 5 years before disease onset.

Results

Our primary multivariate risk models indicated that low socioeconomic status was a strong predictor of ESRD (education: odds ratio [OR], 2.78; 95% confidence interval [CI], 1.49–5.19; income: OR, 2.86, 95% CI, 1.48–5.52), even after adjusting for other risk factors. Other significant predictors for ESRD were a history of hypertension (OR, 3.63–3.90), history of diabetes (OR, 3.85–5.50), and regular intake of folk remedies or over-the-counter Chinese herbs (OR, 10.84–12.51). Regular intake of a multivitamin supplement 5 years before diagnosis was associated with a decreased risk of ESRD (OR, 0.12–0.14).

Conclusions

Our findings indicate that low socioeconomic status, history of hypertension, diabetes, and regular use of folk remedies or over-the-counter Chinese herbs were significant risk factors for ESRD, while regular intake of a multivitamin supplement was associated with a decreased risk of ESRD.Key words: end-stage renal disease, case–control study, risk factors, Taiwan     

Template Matching for Auditing Hospital Cost and Quality

Objective

Develop an improved method for auditing hospital cost and quality.

Data Sources/Setting

Medicare claims in general, gynecologic and urologic surgery, and orthopedics from Illinois, Texas, and New York between 2004 and 2006.

Study Design

A template of 300 representative patients was constructed and then used to match 300 patients at hospitals that had a minimum of 500 patients over a 3-year study period.

Data Collection/Extraction Methods

From each of 217 hospitals we chose 300 patients most resembling the template using multivariate matching.

Principal Findings

The matching algorithm found close matches on procedures and patient characteristics, far more balanced than measured covariates would be in a randomized clinical trial. These matched samples displayed little to no differences across hospitals in common patient characteristics yet found large and statistically significant hospital variation in mortality, complications, failure-to-rescue, readmissions, length of stay, ICU days, cost, and surgical procedure length. Similar patients at different hospitals had substantially different outcomes.

Conclusion

The template-matched sample can produce fair, directly standardized audits that evaluate hospitals on patients with similar characteristics, thereby making benchmarking more believable. Through examining matched samples of individual patients, administrators can better detect poor performance at their hospitals and better understand why these problems are occurring.     

Rehospitalization in a National Population of Home Health Care Patients with Heart Failure

Objective

Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable.

Data Sources

Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services.

Study Design

Retrospective cohort design.

Data Extraction

The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File.

Principal Findings

The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable.

Conclusions

The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates.     

Acute kidney injury after contrast-enhanced examination among elderly

OBJECTIVES:

to assess renal function in elderly patients undergoing contrast-enhanced computed tomography and identify the preventive measures of acute kidney injury in the period before and after the examination.

METHOD:

longitudinal cohort study conducted at the Federal University of São Paulo Hospital, from March 2011 to March 2013. All hospitalized elderly, of both sexes, aged 60 years and above, who performed the examination, were included (n=93). We collected sociodemographic data, data related to the examination and to the care provided, and creatinine values prior and post exam.

RESULTS:

an alteration in renal function was observed in 51 patients (54%) with a statistically significant increase of creatinine values (p<0.04), and two patients (4.0%) required hemodialysis.

CONCLUSION:

There is an urgent need for protocols prior to and post contrast-enhanced examination in the elderly, and other studies to verify the prognosis of this population.