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BACKGROUND:Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States. METHODS:A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days. RESULTS:The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67). CONCLUSIONS:In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.

Anxiety and depression are associated with worse outcomes in several cardiovascular conditions, but it is unclear whether they affect outcomes in atrial fibrillation (AF). In a large diverse population of adults with AF, we evaluated the association of diagnosed anxiety and/or depression with stroke and bleeding outcomes. The Cardiovascular Research Network WAVE (Community-Based Control and Persistence of Warfarin Therapy and Associated Rates and Predictors of Adverse Clinical Events in Atrial Fibrillation and Venous Thromboembolism) Study included adults with AF newly starting warfarin between 2004 and 2007 within 5 health delivery systems in the United States. Diagnosed anxiety and depression and other patient characteristics were identified from electronic health records. We identified stroke and bleeding outcomes from hospitalization databases using validated International Classification of Diseases, Ninth Revision (ICD-9), codes. We used multivariable Cox regression to assess the relation between anxiety and/or depression with outcomes after adjustment for stroke and bleeding risk factors. In 25 570 adults with AF initiating warfarin, 490 had an ischemic stroke or intracranial hemorrhage (1.52 events per 100 person-years). In multivariable analyses, diagnosed anxiety was associated with a higher adjusted rate of combined ischemic stroke and intracranial hemorrhage (hazard ratio, 1.52; 95% confidence interval, 1.01-2.28). Results were not materially changed after additional adjustment for patient-level percentage of time in therapeutic anticoagulation range on warfarin (hazard ratio, 1.56; 95% confidence interval, 1.03-2.36). In contrast, neither isolated depression nor combined depression and anxiety were significantly associated with outcomes. Diagnosed anxiety was independently associated with increased risk of combined ischemic stroke and intracranial hemorrhage in adults with AF initiating warfarin that was not explained by differences in risk factors or achieved anticoagulation quality.

Study Objective: The objective of the study was to assess clinical outcomes (composite of any venous thromboembolism [VTE], any bleeding, and mortality) associated with anti‐Xa monitoring in the 30 days following enoxaparin initiation for VTE prophylaxis. Design: Retrospective cohort study. Setting: Hospital within an academic healthcare system. Patients: Propensity score‐matched hospitalized adults receiving enoxaparin for VTE prophylaxis. Intervention: Low‐molecular‐weight heparin anti‐Xa monitoring. Measurements and Main Results: During the 13‐month study period, a total of 6611 patients received enoxaparin for VTE prophylaxis, 301 in the anti‐Xa monitored group and 6310 in the unmonitored group (4.6% received monitoring). The mean age was 52.9 years and 52% of patients were male. The mean body mass index was 31 kg/m2 and the mean creatinine clearance was 109 mL/min. Twenty percent of patients had active cancer. The most common indication for enoxaparin prophylaxis was hospitalization for medical illness (52%) followed by nonorthopedic surgery (37%). The adjusted odds ratio for the primary outcome comparing monitored to unmonitored patients was 1.26 (95% confidence interval, 0.75–2.11). None of the between‐group differences in the individual components of the composite outcome were statistically significant. Conclusions: Thirty‐day clinical outcomes in patients receiving enoxaparin for VTE prophylaxis were not improved by anti‐Xa monitoring. Our results support current evidence‐based guideline recommendations against anti‐Xa monitoring for patients receiving enoxaparin for VTE prophylaxis. [ABSTRACT FROM AUTHOR]

Background: Despite consensus guideline recommendations, the use of warfarin patient self‐management (PSM) in the United States (US) healthcare system remains underutilized. Objectives: To gain an understanding of the barriers and facilitators to warfarin PSM in US healthcare systems through qualitative exploration of the opinions of select US patients receiving warfarin therapy. Methods: Individual patient interviews were conducted at five geographically diverse sites. Grounded theory analysis was performed on interview transcriptions using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers to PSM implementation within the US healthcare system. Results: A total of 40 patients were interviewed. Four major themes emerged from the interviews: (1) "Patients are resourceful problem solvers who know themselves better than clinicians" (CFIR domain "Characteristics of Individuals"); (2) The provider‐patient relationship is key to successful PSM (CFIR domains "Inner Setting" and "Intervention Characteristics"); (3) Patients are willing and interested in trying PSM if not already doing so (CFIR domains "Process," "Intervention Characteristics," "Inner Setting, and "Characteristics of Individuals"); and (4) Point‐of‐care international normalized ratio (INR) monitoring is an important PSM facilitator (CFIR "Intervention Characteristics," "Outer Setting," "Inner Setting," and "Process" domains). Conclusions: Interview participants were willing and interested in trying PSM. Core elements of warfarin PSM include timely access to INR results, and a framework to support PSM decision making. Home INR monitoring is likely ideal for facilitating PSM implementation as is maintaining strong provider‐patient relationships where providers, including clinical pharmacists, trust their patients and act as a safety net for PSM decision making. [ABSTRACT FROM AUTHOR]

IntroductionRoutine testing for thrombophilia following venous thromboembolism (VTE) is controversial. The use of large datasets to study the clinical impact of thrombophilia testing on patterns of care and patient outcomes may enable more efficient analysis of this practice in a wide range of settings. We set out to examine how accurately algorithms using International Classification of Diseases 9th Revision (ICD-9) codes and/or pharmacy data reflect laboratory-confirmed thrombophilia diagnoses.Materials and methodsA random sample of adult Kaiser Permanente Colorado patients diagnosed with unprovoked VTE between 1/2004 and 12/2010 underwent medical record abstraction of thrombophilia test results. Algorithms using "ICD-9" (positive if a thrombophilia ICD-9 code was present), "Extended anticoagulation (AC)" (positive if AC therapy duration was >6 months), and "ICD-9 & Extended AC" (positive for both) criteria to identify possible thrombophilia cases were tested. Using positive thrombophilia laboratory results as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each algorithm were calculated, along with 95% confidence intervals (CIs).ResultsIn our cohort of 636 patients, sensitivities were low (