2012 February 03

Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation.

Am J Respir Crit Care Med Start a Discussion »

Feb 032012

Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation.

Am J Respir Crit Care Med. 2011 Dec 1;184(11):1289-98

Authors: Sud S, Mittmann N, Cook DJ, Geerts W, Chan B, Dodek P, Gould MK, Guyatt G, Arabi Y, Fowler RA

Abstract
RATIONALE: Venous thromboembolism is difficult to diagnose in critically ill patients and may increase morbidity and mortality.
OBJECTIVES: To evaluate the cost-effectiveness of strategies to reduce morbidity from venous thromboembolism in critically ill patients.
METHODS: A Markov decision analytic model to compare weekly compression ultrasound screening (screening) plus investigation for clinically suspected deep vein thrombosis (DVT) (case finding) versus case finding alone; and a hypothetical program to increase adherence to DVT prevention. Probabilities were derived from a systematic review of venous thromboembolism in medical-surgical intensive care unit patients. Costs (in 2010 $US) were obtained from hospitals in Canada, Australia, and the United States, and the medical literature. Analyses were conducted from a societal perspective over a lifetime horizon. Outcomes included costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios.
MEASUREMENTS AND MAIN RESULTS: In the base case, the rate of proximal DVT was 85 per 1,000 patients. Screening resulted in three fewer pulmonary emboli than case-finding alone but also two additional bleeding episodes, and cost $223,801 per QALY gained. In sensitivity analyses, screening cost less than $50,000 per QALY only if the probability of proximal DVT increased from a baseline of 8.5-16%. By comparison, increasing adherence to appropriate pharmacologic thromboprophylaxis by 10% resulted in 16 fewer DVTs, one fewer pulmonary emboli, and one additional heparin-induced thrombocytopenia and bleeding event, and cost $27,953 per QALY gained. Programs achieving increased adherence to best-practice venous thromboembolism prevention were cost-effective over a wide range of program costs and were robust in probabilistic sensitivity analyses.
CONCLUSIONS: Appropriate prophylaxis provides better value in terms of costs and health gains than routine screening for DVT. Resources should be targeted at optimizing thromboprophylaxis.

PMID: 21868500 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Proton Pump Inhibitor Use and Recurrent Clostridium difficile-associated Disease: A Case-control Analysis Matched by Propensity Score.

J Clin Gastroenterol Start a Discussion »

Feb 032012

Proton Pump Inhibitor Use and Recurrent Clostridium difficile-associated Disease: A Case-control Analysis Matched by Propensity Score.

J Clin Gastroenterol. 2012 Jan 30;

Authors: Kim YG, Graham DY, Jang BI

Abstract
BACKGROUND AND AIM:: Clostridium difficile has been increasingly diagnosed in hospitalized patients. An association between proton pump inhibitors (PPIs) use and Clostridium difficile-associated disease (CDAD) and between recurrent CDAD has been suggested. The aim of this study is to investigate whether PPI use is associated with the development of recurrent CDAD. METHODS:: This was a retrospective case-control study of patients with CDAD at Yeungnam University Medical Center, seen from January 2004 to December 2008. C. difficile infection was diagnosed by the presence of C. difficile toxin in the stool. Those with recurrent disease were matched with nonrecurrent controls using multivariate matched sampling methods that incorporated the propensity score. RESULTS:: Recurrent CDAD developed in 28 (14.1%) of the 198 patients with diarrhea and positive C. difficile stool toxin assays. Multivariate analysis of the total population of recurrent versus nonrecurrent CDAD revealed that additional use of non-C. difficile antimicrobial therapy (concomitant with the treatment or after or both), poor response to therapy with metronidazole or vancomycin, and recent gastrointestinal surgery were risk factors for recurrent CDAD. We were able to match 21 recurrent CDAD subjects with 21 without recurrent CDAD. Among the matched patients only PPI use was associated with recurrent CDAD (ie, 47.6% vs. 4.8%, P=0.004 for recurrent vs. nonrecurrent CDAD, respectively). CONCLUSIONS:: Among the matched patient groups, only PPI therapy was associated with recurrent CDAD. Prospective studies are needed to clarify whether avoidance of PPIs or specific cotherapies will reduce the incidence of recurrent C. difficile-associated diarrhea.

PMID: 22298089 [PubMed - as supplied by publisher]

Link to Article at PubMed

Medication reconciliation: identifying medication discrepancies in acutely ill hospitalized older adults.

Am J Geriatr Pharmacother Start a Discussion »

Feb 032012

Medication reconciliation: identifying medication discrepancies in acutely ill hospitalized older adults.

Am J Geriatr Pharmacother. 2011 Oct;9(5):339-44

Authors: Villanyi D, Fok M, Wong RY

Abstract
BACKGROUND: Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medication reconciliation involves verifying medication use and identifying and rectifying discrepancies.
OBJECTIVE: The aim of this study was to describe the prevalences and types of medication discrepancies in acutely ill older patients.
METHODS: Patients who were ? 70 years and were admitted to any of 3 acute care for elders (ACE) units over a period of 2 nonconsecutive months in 2008 were prospectively enrolled. Medication discrepancies were classified as intentional, undocumented intentional, and unintentional. Unintentional medication discrepancies were classified by a blinded rater for potential to harm. This study was primarily qualitative, and descriptive (univariate) statistics are presented.
RESULTS: Sixty-seven patients (42 women; mean [SD] age, 84.0 [6.5] years) were enrolled. There were 37 unintentional prescription-medication discrepancies in 27 patients (40.3%) and 43 unintentional over-the-counter (OTC) medication discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation Success Index (MRSI) of 89% for prescription medications and 59% for OTC medications. The overall MRSI was 83%. More than half of the prescription-medication discrepancies (56.8%) were classified as potentially causing moderate/severe discomfort or clinical deterioration.
CONCLUSION: Despite a fairly high overall MRSI in these patients admitted to ACE units, a substantial proportion of the prescription-medication discrepancies were associated with potential harm.

PMID: 21890424 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Impact of different discharge patterns on bed occupancy rate and bed waiting time: a simulation approach.

j med eng technol Start a Discussion »

Feb 032012

Impact of different discharge patterns on bed occupancy rate and bed waiting time: a simulation approach.

J Med Eng Technol. 2011 Aug-Oct;35(6-7):338-43

Authors: Zhu Z

Abstract
Beds are one of the most important resources in a healthcare system. How to manage beds efficiently is an important indicator of the efficiency of the healthcare system. Bed management is challenging to many healthcare service providers in many aspects. In recent years, population growth and aging society impose extra pressure on bed requirement. There are usually two key performance indicators of a bed management system: bed occupancy rate and bed waiting time. In this paper, different discharge patterns and their impacts on the bed occupancy rate and bed waiting time are studied. A discrete event simulation model is constructed to evaluate the existing discharge pattern in a Singapore regional hospital using actual hospital admission and discharge transaction data. Then different discharge patterns are tested in the same context. Simulation results show that a proper discharge pattern significantly smoothes the fluctuation of bed occupancy rate and reduce the bed waiting time.

PMID: 21916602 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Risk factors associated with carotid artery puncture following landmark-guided internal jugular vein cannulation attempts.

Med Princ Pract Start a Discussion »

Feb 032012

Risk factors associated with carotid artery puncture following landmark-guided internal jugular vein cannulation attempts.

Med Princ Pract. 2011;20(6):562-6

Authors: Jankovic RJ, Pavlovic MS, Stojanovic MM, Stosic BS, Milic DJ, Ignjatovic NS, Bogicevic AN, Djordjevic DR, Savic NN

Abstract
OBJECTIVE: The relationship between certain risk factors and carotid artery puncture (CAP) as an early mechanical complication following internal jugular vein cannulation attempts (IJVCAs) was evaluated.
METHODS: In a retrospective 1-year observational single-center study, 86 IJVCAs conducted in the operating room by 4 competent anesthesiologists were evaluated. Age, gender, puncture side, number of cannulation attempts, circumstances of the procedure and incidence of CAP were obtained from medical records.
RESULTS: Of the 86 IJVCAs performed in patients aged 18-75 years, CAP occurred in 8 (9.3%): 5 (5.8%) in patients >65 years and 3 (3.5%) in patients <65 years of age. CAP was not associated with patient's age (p = 0.11) and gender (p = 0.76). Multiple cannulation attempts (OR = 26.25; 95% CI = 4.52-152.51; p < 0.001) and placement of CVC under emergency conditions (OR = 14.84; 95% CI = 1.73-127.22; p = 0.014) increased the risk for CAP significantly. Also, the risk for CAP was higher when IJVCAs were performed before induction of general anesthesia (OR = 15.75; 95% CI = 1.83-135.1; p = 0.019). CAP was more likely to happen during left-sided than right-sided IJVCA (OR = 5.98; 95% CI = 1.29-27.59; p = 0.022). In addition, left-sided attempts considerably increased the risk for multiple cannulation attempts (OR = 2.782; 95% CI = 1.342-3.965; p < 0.01). Also, manifold cannulation attempts were more frequent if the IJVCA was performed before induction of anesthesia (OR = 4.219; CI = 1.579-11.271; p = 0.004).
CONCLUSIONS: Our results strongly suggest that left-sided, multiple IJVCAs, performed under emergency conditions in conscious patients in the operating room, represent considerable risks for possible CAP.

PMID: 21986016 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Prevalence and predictors of warfarin use in patients with atrial fibrillation at low or intermediate risk and relation to thromboembolic events.

Clin Cardiol Start a Discussion »

Feb 032012

Prevalence and predictors of warfarin use in patients with atrial fibrillation at low or intermediate risk and relation to thromboembolic events.

Clin Cardiol. 2011 Oct;34(10):640-4

Authors: Chae SH, Froehlich J, Morady F, Oral H

Abstract
BACKGROUND: According to the American College of Cardiology/American Heart Association/European Society of Cardiology guidelines, the choice of aspirin or warfarin to prevent thromboembolic events (TEs) in patients with nonrheumatic atrial fibrillation (AF) should be based on the CHADS(2) score. The purpose of this study was to determine the predictors of warfarin use in patients with AF at low (CHADS(2) =0) or intermediate (CHADS(2) =1) risk for TEs.
HYPOTHESIS: Warfarin use is low in intermediate- and low-risk patients.
METHODS: Clinical characteristics of 3086 consecutive patients (mean age, 70 ± 13 years) with nonrheumatic AF from an academic multispecialty practice were determined between 2006 and 2008 through individual chart review. Patients were identified based on an inpatient or outpatient encounter, in which a billing diagnosis code of AF or atrial flutter (AFl) was recorded. The decision for anticoagulation was at the discretion of the primary care physician or cardiologist. No intervention to guide anticoagulant therapy was made.
RESULTS: Warfarin was prescribed in 180/497 low-risk patients (36%), and in 646/938 intermediate-risk patients (69%). Among high-risk patients (CHADS(2) ?2), warfarin was used in 792/968 patients (82%) with a CHADS(2) = 2, in 343/410 patients (84%) with a CHADS(2) =3, and in 225/273 patients (82%) with a CHADS(2) ?4. On multivariate analysis, independent predictors of warfarin use in low-risk patients were nonparoxysmal AF (odds ratio [OR]: 5.02, P<0.0001) and age between 65 and 74 years (OR: 2.21, P<0.0001). Among intermediate-risk patients, congestive heart failure (OR: 7.34, P<0.0001), nonparoxysmal AF (OR: 4.04, P<0.0001), coronary artery disease (OR: 2.53, P<0.0001), age between 65 and 74 years (OR: 1.68, P = 0.002), and female gender (OR: 1.69, P = 0.002) were independent predictors of warfarin use. Lack of warfarin use (OR: 4.9, P<0.001) and female gender (OR: 2.0, P = 0.03) were associated with a higher risk of TEs in intermediate-risk patients. None of the CHADS(2) parameters was predictive of TEs. Warfarin was not associated with reduction in TEs in low-risk patients. Warfarin use did not have a significant effect on bleeding.
CONCLUSIONS: Although either aspirin or warfarin is recommended to prevent TEs in patients with AF at intermediate risk for TEs, warfarin is preferred in the majority of patients in general practice. Lack of warfarin use is associated with a higher risk of TEs in intermediate-risk patients with AF. The adoption of new oral anticoagulants that have lower risk of major hemorrhage than warfarin for low- or intermediate-risk AF patients remains to be determined.

PMID: 21994084 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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