Care For Venous Thromboembolism Research Articles

Venous thromboembolism in the era of machine learning and artificial intelligence in medicine

In this review, we embark on a comprehensive exploration of venous thromboembolism (VTE) in the context of medical history and its current practice within medicine. We delve into the landscape of artificial intelligence (AI), exploring its present utility and envisioning its transformative roles within VTE management, from prevention to screening and beyond. Central to our discourse is a forward-looking perspective on the integration of AI within VTE in medicine, advocating for rigorous study design, robust validation processes, and meticulous statistical analysis to gauge the efficacy of AI applications. We further illuminate the potential of large language models and generative AI in revolutionizing VTE care, while acknowledging their inherent limitations and proposing innovative solutions to overcome challenges related to data availability and integrity, including the strategic use of synthetic data. The critical importance of navigating ethical, legal, and privacy concerns associated with AI is underscored, alongside the imperative for comprehensive governance and policy frameworks to regulate its deployment in VTE treatment. We conclude on a note of cautious optimism, where we highlight the significance of proactively addressing the myriad challenges that accompany the advent of AI in healthcare. Through diligent design, stringent validation, extensive education, and prudent regulation, we can harness AI's potential to significantly enhance our understanding and management of VTE. As we stand on the cusp of a new era, our commitment to these principles will be instrumental in ensuring that the promise of AI is fully realized within the realm of VTE care.

Updated review on malignancy-associated venous thromboembolism: Pathogenesis and comparison between various therapeutic modalities

Venous thromboembolism (VTE) is one of the life-threatening complications in cancer patients, the incidence of which is affected by the patient and malignancy-related variables. Location, type, therapeutic route, stage, grade, and non-supportive treatment of the cancer are the most important VTE risk factors. Patient age, ethnicity, and concomitant genetic or acquired comorbidities or thrombophilias are known risk factors for VTE in cancer. All high-risk cancer patients admitted to hospitals or treated as outpatients should receive VTE prophylaxis. Low molecular weight heparin is the main treatment for active malignant VTE. Vitamin K antagonists and non-Vitamin K-dependent oral anticoagulants are used in stable, non-bleeding cancer patients. Anticoagulation should be continued until the cancer is treated or at least controlled. Over the past two decades, randomized clinical and observational trials have improved the pathogenesis and therapeutic knowledge of VTE, but many challenges remain. The lack of an optimal primary prophylaxis method for inpatients and outpatients in oncology and the care of cancer-associated VTE in standard and high-bleeding risk groups are examples for which more clinical research on cancer-associated thrombosis is necessary to address these issues. In this review, we describe the pathogenesis, factors that increase the risk of VTE, and the comparison between the effectiveness of available anticoagulants in the treatment and prevention of VTE in cancer patients.

Surveying Patients' Experiences and Perspectives on Venous Thromboembolism Care: An International Study to Identify Gaps and Opportunities in Health Care Delivery

Background Patient experience is a well-recognized, independent dimension of health care delivery. Although considerable progress has been made in the diagnosis and management of venous thromboembolism (VTE), data on the patient experience are lacking. We aimed to capture patients' experiences with VTE and anticoagulation in order to prioritize efforts to improve VTE health care delivery. Methods An IRB-approved survey was developed with a multidisciplinary team of clinicians and patient advocates. The survey domains included patient demographics, health care experiences, perspectives, and potential gaps in healthcare received for VTE. The survey was pilot tested and subsequently distributed electronically from May-July 2023 through an international patient advocacy group targeting individuals with personal history of VTE. Data are described as counts and proportions. We used log binomial regression to calculate the risk ratios (RR) and 95% confidence intervals (CI) of outcomes associated with seeing a hematologist during or after hospital admission. Results Of a total of 1,050 participants, the majority were from the US (81%), including 49 states and the District of Columbia. A response rate could not be calculated given that the web-based survey was openly distributed. The majority of respondents were women (81%), 88% identified as white, and 71% were age 40-69 years. Most patients (68%) experienced their first VTE event >12 months prior to the study, 36% had >1 VTE events and the majority (62%) were diagnosed in the emergency department. Over one-third (35%) of respondents reported not receiving the correct diagnosis the first time they presented to medical care and 50% of these participants had at least 3 health care visits before reaching the correct diagnosis. The majority (93%) recall information regarding their VTE diagnosis was provided by physicians or advanced practitioners, 65% reported this conversation was <10 minutes, and only 55% felt the diagnosis was explained to their satisfaction. (Table) A minority (16%) of patients received printed or electronic information at the time of diagnosis. Almost all (97%) participants were treated with anticoagulation, but only 48% recalled being provided specific information about the medication including risks and benefits. Only 24% of 563 respondents who menstruate recall discussing the impact of anticoagulation on menstruation with providers, and all recalled discussing this only after they developed anemia or changes in their menstrual flow. Of the 105 participants who were offered the opportunity to speak with a health care advocate, most (73%) accepted it; of those not offered an advocate, 88% reported that they would have accepted the opportunity. Only 53% of respondents reported access to providers for questions regarding their VTE diagnosis. Of 702 patients who were admitted to the hospital for VTE, 32% reported returning to health care, as their symptoms did not improve or worsened, and 30% of these patients were readmitted. Most admitted patients (89%) reported receiving some information about VTE at discharge, but the information received did not match the topics patients wanted. For example, patients most frequently wanted information about support groups (65%), mental health (65%), recurrence risk (55%) and prevention strategies (49%), but few received this information (2%, 2%, 17%, and 33%, respectively (Figure). Most patients were seen by hematologists following discharge (59%) or during hospitalization (35%). Among admitted patients, those who saw a hematologist either during or after admission were significantly more likely to receive information about their VTE (RR: 1.15, 95% CI: 1.06-1.24) and about anticoagulation (RR: 1.23, 95% CI: 1.04-1.45) at discharge compared to patients who did not see a hematologist. Conclusion In this first large-scale international survey to capture patient experiences and gaps in VTE care delivery, we identified several potential areas for improvement. Efforts to enhance patient education could improve the patient experience. Further research could explore if better education translates to improved medication adherence, management of bleeding, avoiding polypharmacy, and ultimately clinical outcomes. Professional societies and patient advocacy groups can partner to build resources to improve the quality of care and patient satisfaction for people with VTE.

Patient-Reported Outcomes in Venous Thromboembolism: A Systematic Review of the Literature, Current Challenges, and Ways Forward.

Venous thromboembolism (VTE) affects >1.2 million Americans annually. Although the clinical outcomes and economic burdens of VTE have been well described, the impact of VTE on patients' health status has yet to be summarized. This systematic review summarizes how patient-reported outcome measures (PROMs) have been used in VTE to date. PubMed/MEDLINE was queried for literature published through March 2023 using PROMs in a population of patients with VTE. Studies were excluded if the reference was an editorial, review, or case report, or if the study included patients with conditions other than VTE. Qualitative analyses were performed. After screening and exclusion, 136 references were identified; 5 described PROM development, 20 focused on PROM validation, and 111 used PROMs in outcomes research. The most used generic PROMs were the 36-item Short-Form Health Survey and EuroQol 5-dimensional questionnaire, and the most common disease-specific PROMs were the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms and the Pulmonary Embolism Quality of Life Questionnaire. PROMs were used to quantify the changes in health status after diagnosis, characterize the trajectory of subsequent improvement, and identify drivers of continued impairments in health status like postthrombotic syndrome and postpulmonary embolism syndrome. PROMs were also used to investigate the impact of novel treatment modalities on quality of life. This review demonstrates the many benefits of PROM use, including quantifying changes in health status with treatment, capturing patients' experiences with the treatment itself, and identifying complications of VTE. Incorporating PROMs into VTE care will be an essential component of evaluating the effectiveness of novel therapies and should lead to improved shared decision-making for patients with VTE.

The Post-Venous Thromboembolism Functional Status Scale: From Call to Action to Application in Research, Extension to COVID-19 Patients, and Its Use in Clinical Practice.

A broad spectrum of long-term sequelae may be present in venous thromboembolism (VTE) survivors, affecting their quality of life and functioning. To monitor recovery and improve the prognosis of patients with persistent functional limitations, the development of a new outcome measure that could better capture the consequences of VTE was an unmet need. Starting as a call to action, the Post-VTE Functional Status (PVFS) scale was developed to meet this need. The PVFS scale is an easy-to-use clinical tool to measure and quantify functional outcomes after VTE by focusing on key aspects of daily life. As the scale was considered useful in coronavirus disease 2019 (COVID-19) patients as well, the Post-COVID-19 Functional Status (PCFS) scale was introduced early in the pandemic after slight adaptation. The scale has been well incorporated into both the VTE and COVID-19 research communities, contributing to the shift of focus toward patient-relevant functional outcomes. Psychometric properties have been evaluated, mainly for the PCFS scale but recently also for the PVFS scale, including validation studies of translations, showing adequate validity and reliability. In addition to serving as outcome measure in studies, guidelines and position papers recommend using the PVFS and PCFS scale in clinical practice. As broad use of the PVFS and PCFS scale in clinical practice is valuable to capture what matters most to patients, widespread implementation is a crucial next step. In this review, we discuss the development of the PVFS scale and introduction in VTE and COVID-19 care, the incorporation of the scale in research, and its application in clinical practice.

Utilization of the Khorana score (KS) by hematology/oncology clinicians in the ambulatory setting.

31 Background: Patients with cancer are at an increased risk for venous thromboembolism (VTE). Though cancer-associated thrombosis is a major cause of mortality in patients, only second to disease progression, the optimal use of primary prophylaxis remains a clinical challenge. The KS, developed in 2008, is a validated tool to identify patients at low, intermediate, and high-risk for VTE. At the UConn Health Neag Comprehensive Cancer Center, we created a survey and administered it amongst our clinicians to assess KS knowledge and documentation practices. Methods: We conducted a 3-part quality improvement study that included a pre- and post-intervention retrospective chart review of eligible patients with cancer to examine rates of KS documentation. Eligibility included patients with cancer initiating a new chemotherapy. We excluded patients on anticoagulation, multiple myeloma, brain/central nervous system tumors, and patients in the Department of Corrections. The interventions included: 1) 9-question survey to assess clinician knowledge and utilization of KS; 2) KS education presented at a clinician meeting; 3) an electronic medical record (EMR) tool implemented to standardize KS documentation; and 4) reminder KS tip sheet created for clinicians. Descriptive statistics were used in data analysis. Results: Of 50 documented encounters, 40 met study criteria, with none having KS documentation. In a pre-tool implementation survey sent to 24 clinicians, of whom 20 had participated, 70% were physicians, 30% were advanced practice registered nurses (APRN), and 60% reported being in practice for 5 years or less. Most (90%) reported not using KS; only 10% reported being unfamiliar with the KS while 65% reported only sometimes talking to patients about VTE risk. Of the 10% of clinicians that did document KS, it was reported that they “document in the narrative of [the] note when appropriate.” The highest barriers to documentation were reported as “time constraints with extra documentation” and “not enough guidance.” Post-EMR tool implementation, a total of 58 of 99 (58.5%) encounters met study criteria and 1 KS was documented (1.7%). Conclusions: KS is underutilized in ambulatory clinical settings partly due to a lack of education and awareness despite availability of national guidelines which reflect the importance of primary VTE prophylaxis evaluation in all patients with cancer. This study demonstrates a continued deficiency in our clinical practice. We aim to further identify barriers and methods for improvement of KS documentation and VTE risk assessments. Additionally, a referral process is planned for all at-risk patients to enhance patient care, decrease hospital visits related to VTE, and attempt to reduce health-care costs related to VTE care.

Venous-thromboembolism and associated health care utilization in elderly patients with diffuse large B cell lymphoma.

Patients with lymphoma have an increased risk of venous thromboembolism (VTE). The authors examined the risk of VTE and subsequent health care utilization in elderly patients with diffuse large B cell lymphoma (DLBCL). A total of 5537 DLBCL patients ≥66 years old enrolled in Medicare from the Surveillance, Epidemiology, and End Results registry and a noncancer control group of Medicare beneficiaries (n = 5537) were identified. Cumulative incidence function to examine the risk of VTE 12 months after DLBCL diagnosis was used. Fine and Gray method was used to examine the risk factors associated with VTE risk in multivariable models. Total number of hospitalizations, outpatient visits, and Medicare spending were compared in DLBCL patients with and without VTE. VTE was diagnosed in 8.3% DLBCL patients and 1.5% controls, yielding an 8.6-fold higher risk of VTE in DLBCL in adjusted analysis (95% confidence interval [CI], 6.62-11.20; P < .001). Multivariable regression analysis showed that precancer VTE history was associated with an increased risk of developing VTE after a DLBCL diagnosis (hazard ratio [HR], 5.39; 95% CI, 4.39-6.63), and Asian individuals were associated with a lower risk (HR, 0.54; 95% CI, 0.29-1.00). Patients newly diagnosed with VTE after lymphoma had a 1.7-fold higher rate of hospitalization and a 1.2-fold higher rate of outpatient visits compared to those without, resulting in excess Medicare spending of $22,208 in the first year after DLBCL diagnosis. Elderly patients with DLBCL have an elevated risk of VTE resulting in excess health care utilization. VTE history before DLBCL was associated with increased risk of post-DLBCL VTE, and Asian individuals were associated with a lower risk of VTE.

Engaging Early-Career Physicians in Medical Device Innovation and Entrepreneurship.

Engaging Early-Career Physicians in Medical Device Innovation and Entrepreneurship.

Factor Xa Inhibition for the Treatment of Venous Thromboembolism Associated With Cancer: A Meta-Analysis of the Randomised Controlled Trials

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients. Until recently, guidelines recommended the use of low-molecular weight heparin (LMWH) as standard of care for VTE in patients with cancer. Despite the proven efficacy of direct oral anticoagulants (DOACs) for treatment of VTE, there is equipoise supporting their use in cancer patients. A systematic review of PubMed, Medline and EMBASE identified four randomised controlled trials (RCTs) in patients with cancer and VTE comparing a factor Xa inhibitor (FXaI) to LMWH. A meta-analysis was performed with a primary outcome of VTE recurrence and key secondary outcomes of major bleeding, clinically relevant non-major bleeding (CRNMB) and gastrointestinal (GI) bleeding. Four RCTs with 2,907 patients were included. 1,451 patients were randomised to FXaI and 1,456 to LMWH. VTE recurrence was lower in the FXaI group (RR 0.62, 95%CI 0.44-0.87; p=0.01; I2=24.90), with an absolute risk difference of -4% equating to a number needed to treat of 25 for prevention of recurrent VTE with FXaI. No significant difference in major bleeding was noted between groups (RR 1.33, 95%CI 0.84-2.11; p=0.23). Rates of GI bleeding (RR 1.87, 95%CI 1.06-3.29; p=0.03) and CRNMB (RR 1.57, 95%CI 1.11-2.23; p=0.01) were greater with FXaIs. In patients with cancer and VTE, the rate of VTE recurrence was significantly lower with FXaI than with LMWH without an increased risk of major bleeding. Our data supports the use of FXaIs as the standard of care for the treatment of VTE in this population.

Patient- and Health-Care-Provider-Reported Outcomes to Consider in Research on Pregnancy-Associated Venous Thromboembolism

Venous thromboembolism (VTE) in pregnancy can have numerous adverse impacts on patients and health care systems. Ongoing research aimed at improving maternal and fetal/neonatal outcomes is hampered by the lack of patient perspective in determining which outcomes are considered important to assess the effectiveness of interventions. The objective of this study was to elicit outcomes from those who experienced or were at risk for pregnancy-associated VTE (health service users, HSUs) and health care providers (HCPs) involved in their care. Canadian HSUs and HCPs were recruited using convenience and purposive sampling, respectively. Individual, semistructured interviews aimed specifically at eliciting pregnancy-related outcomes were conducted until data saturation was attained. Interviews were audio-recorded and transcribed verbatim. Written transcripts were de-identified and interpretatively analyzed in duplicate to obtain outcomes related to participant experiences. Outcomes were grouped based on a taxonomy developed for medical research and compared between and across interviews with patients and HCPs, and with those obtained through a systematic review of the published literature. We interviewed 10 HSUs and eight HCPs and elicited 52 outcomes, 21 of which have not been reported in the literature. Although the majority of elicited outcomes were in the clinical/physiological core outcome area, both HSUs and HCPs highlighted the importance of outcomes related to functioning/life impact and general wellbeing of mother and baby. These outcomes representing the perspectives of HSUs and HCPs should be considered while conducting trials on pregnancy-associated VTE.

Pharmacoeconomic, Medication Access, and Patient-Satisfaction Analysis of a Pharmacist-Managed VTE Clinic Compared to Primary Care Physician Outpatient Therapy

Venous thromboembolism (VTE) is a common medical condition often treated with direct oral anticoagulants (DOACs). Current literature supports outpatient treatment of select, low-risk VTE patients by a pharmacist with DOACs; however, no studies exist to demonstrate if a pharmacist-managed VTE clinic provides financial benefit compared to physician-managed outpatient care. To compare the financial implications and patient satisfaction of pharmacist-managed VTE care versus outpatient VTE care by a primary care physician. A single-center retrospective chart review was conducted on all patients seen at a pharmacist-managed VTE clinic for safety and reimbursement outcomes between August 1, 2018 and July 31, 2019. These data points were used to assess the primary endpoint of net gain per patient visit and secondary outcomes, including patient satisfaction score. The primary outcome median (IQR) for net gain per visit was $16.57 (16.57, 16.57) for the pharmacist-managed group and $64.37 (47.04, 64.37) in the physician-managed group with a 95% CI of 39.13-47.80. The median cost to the organization per visit was $4.96 (4.96, 4.96) for the pharmacist-managed group and $39.41 (23.65, 39.41) for the physician managed group with a 95% CI of 26.57-34.45. Statistical difference was also found for a secondary outcome of percentage of days covered for the pharmacist-managed group compared to the physician managed group, median (IQR) 100% (76,100) vs 92.2% (67.2, 98.9) respectfully, with a p-value of 0.043. The pharmacist-managed VTE clinic, although financially sustainable, provides significantly less net revenue per patient than physician managed clinics, demonstrating the need for increased payer recognition for pharmacists.

Assessment of Nurses’ Knowledge and Practice about Venous Thrombo Embolism for Cancer Surgery Patients

Background: Venous thromboembolism (VTE) a common complication and important cause of death. VTE consists of two forms: deep vein thrombosis (DVT) and pulmonary embolism (PE) venous thrombo embolism (VTE). Aim assess nurses’ knowledge and practice about venous thrombo embolism for cancer surgery patients. Study design: A descriptive research design used in the study. Setting: The study was conducted in the surgical unit, at Aswan oncology center. Subjects: The study included on a convenience sample (30) nurses working in surgical unit, at Aswan oncology center. Tools: two tools were used for data collection, a structured Interview questionnaire sheet for nurses and an observation check list for nurses practice Result: The total score of Nurses' knowledge about VTE were unsatisfactory level (96.7%), also the total score of observed nurses' practice level regarding prevention was unsatisfactory (93.3%). Conclusion: Nurses` knowledge and practice levels regarding the care of Venous Thrombo Embolism for Cancer Surgery Patients and venous thromboembolism prevention were unsatisfactory which needed an improvement. Recommendation: Nurses needed for in-service training programs and increase awareness to update their knowledge and practice regarding the care of Venous Thrombo Embolism for Cancer Surgery Patients.

475 Direct Oral Anticoagulant Therapy Versus Low-Molecular Weight Heparin for the Treatment of Venous Thrombo-Embolism Associated With Cancer

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients. Current guidelines dictate the use of low-molecular weight heparin (LMWH) as standard of care for VTE in patients with cancer. Despite the proven efficacy of direct oral anticoagulants (DOACs) for treatment of VTE, there is equipoise supporting their use in patients with cancer. A systematic review of PubMed, MEDLINE and EMBASE identified four randomised controlled trials (RCTs) in patients with cancer and VTE comparing DOAC to LMWH. A meta-analysis was performed with a primary outcome of VTE recurrence and secondary outcomes of major bleeding and gastrointestinal (GI) bleeding. A total of 4 RCT with 2,899 patients were included. 1,466 patients were randomized to DOAC therapy and 1,448 to LMWH. VTE recurrence was significantly lower in the DOAC group (RR 0.62, 95% CI 0.44–0.87; p=0.01; I2=24.90). There was an absolute risk difference of -4% that equates to an NNT of 25 for prevention of recurrent VTE. No significant differences in major bleeding was noted between groups (RR 1.33, 95% CI 0.84–2.11; p=0.23) although rates of GI bleeding was greater in the DOAC group (RR 1.87, 95% CI 1.06–3.29; p=0.03). In patients with cancer and VTE, the rate of VTE recurrence was significantly lower with DOAC than with LMWH without an increased risk of major bleeding. Our data supports the use of DOACs as the standard of care for the treatment of VTE in patients with cancer.

Práticas De Prevenção De Pneumonia Associada À Ventilação Mecânica Em Terapia Intensiva

Objetivo: identificar a adesão a práticas de prevenção de Pneumonia Associada à Ventilação Mecânica (PAV) em Unidade de Terapia Intensiva (UTI). Método: estudo transversal, descritivo, de abordagem quantitativa. Foi realizado em UTI de hospital universitário público do Paraná. A adesão às práticas de prevenção da PAV foi extraída de prontuários e observação direta dos pacientes, por meio de lista de verificação dicotômica embasada nas principais ações preventivas recomendadas pela literatura. Aos dados tabulados, procedeu-se análise estatística descritiva. Resultados: As práticas mais aderidas para a prevenção de PAV foram: manutenção da cabeceira elevada 30-45º (n=79; 100%) e controle da pressão de cuff (72; 91,1%). Houve 32 (40,5%) prontuários sem registros de higiene oral realizada. Entre as práticas não aderidas, destaca-se a não interrupção (n=64; 81%) da sedação. Ademais, cuidados de profilaxia de tromboembolismo venoso e úlcera péptica não foram realizados. Conclusão: a adesão às práticas de prevenção da PAV tem ênfase em ações de teor rotineiro.

Heavy Menstrual Bleeding Under-Recognized in Menstruating Women Treated with Oral Anticoagulants

Background: Reproductive-age women are at increased risk of venous thromboembolism (VTE) due to increased estrogen states, such as pregnancy and the use of estrogen-based medications. The use of oral anticoagulants (OACs), the standard of care for VTE, is associated with increased rates of heavy menstrual bleeding (HMB), defined as &amp;gt;80 mL loss of blood per cycle, in this patient population. In addition to a need for interventions, ranging from initiation of hormonal therapy to surgical management of bleeding, HMB is a deterrent for adherence to OAC. Decreased adherence, such as temporary discontinuation, is associated with an increased risk of recurrent VTE. This is particularly true for women treated with rivaroxaban, for whom the literature suggests the risk of HMB and other forms of abnormal uterine bleeding is increased two-fold, as compared to warfarin. Methods: We performed a retrospective cohort study of reproductive-aged (18-50 years) women receiving oral anticoagulant therapy at a single tertiary care center between January 1, 2012 and December 31, 2018. Female subjects within the appropriate age range were identified using a Cohort Discovery Tool, a web-based interface which allows investigators to query an underlying research data warehouse that contains electronic health record data for the Oregon Health &amp; Science University healthcare system. Medical record review was performed on all identified records to confirm inclusion criteria, including a documented visit with a primary care provider within 6 months following initial prescription. Exclusions included surgical menopause, pregnancy within 6 months of initial prescription, and lactation within 3 months. We abstracted demographic information, initial anticoagulant prescription and indication, menstrual bleeding history, hormonal therapy and HMB specific medical or surgical treatment within 6 months of initial prescription. Results: A total of 236 eligible subjects were identified. The majority (40.6%) were prescribed rivaroxaban as compared to apixaban (25.2%) or warfarin (34.2%). Most (67.1%) were receiving anticoagulation for the treatment of VTE although 20.1% were anticoagulated for 'other' reasons, including superficial thrombophlebitis and prophylaxis in the post-operative setting or for travel. For the majority of subjects (59.8%), no discussion of menstrual history was documented prior to or at the time of initial prescription. Twenty-nine percent of women received medical (including hormonal) or surgical therapy for HMB, including 32.6% of women treated with rivaroxaban, 23.7% of women treated with apixaban and 28.8% of women treated with warfarin (p &amp;lt;0.001). Discussion: Our study confirms prior reports of increased prevalence of HMB and other abnormal uterine bleeding in women prescribed rivaroxaban as compared to apixaban or warfarin. Our overall numbers, however, are lower than those previously reported in the literature, where HMB, defined as blood loss of &amp;gt;80mL/cycle or a pictorial blood loss assessment chart score of &amp;gt;100, is reported in 66% of warfarin users. We used a different definition of HMB, which was any menstrual bleeding severe enough to require an intervention, including hormonal therapy, surgery or iron replacement, which may explain this difference. Not all women with standardly defined HMB may require such therapies. However, since the vast majority of providers did not assess for menstrual bleeding at the time of drug initiation, it is possible that HMB was unrecognized. Our next step will be to survey women who received an initial prescription in 2017 or 2018 regarding symptoms of HMB, in order to assess the proportion of subjects whose diagnosis of HMB went undetected. Our findings underscore the importance of addressing and discussing menstrual bleeding with menstruating women using oral anticoagulants. Disclosures No relevant conflicts of interest to declare.

Understanding Factors Associated with Quality of Life in Patients with Venous Thromboembolism.

Quality of life (QoL) deficits have been noted among patients with venous thromboembolism (VTE) but understanding of the drivers of that poorer QoL is limited. The objective of this study was to examine associations between a variety of factors and QoL in patients with VTE. Adult patients who had experienced at least one VTE episode within the past 2 years completed an online survey between May and July 2016 with responses to a variety of questions designed to ascertain QoL scores, Optum Short Form-12, and potential factors associated with these scores. Most of the 907 patients were female (56.7%) and Caucasian (88.6%). Physical and mental QoL scores below the general population average were present in 76.0 and 56.7% of patients, respectively. Multiple regression modeling revealed several factors associated with below average physical QoL scores including unemployment (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.76-8.05), gastrointestinal bleeding (OR 2.54, 95% CI 1.28-5.01), high depression scores (OR 4.02, 95% CI 1.88-8.58), or difficulty accessing VTE care (OR 4.24, 95% CI 1.77-10.17). Factors associated with below average mental QoL scores included experiencing VTE within the last month (OR 3.85, 95% CI 1.58-9.41), unemployment (OR 2.83, 95% CI 1.30-6.16), or high depression (OR 3.85, 95% CI 1.60-9.28) and/or anxiety (OR 9.17, 95% CI 4.81-17.47) scores. Most patients with recently diagnosed VTE reported below average QoL. Many of the factors associated with below average QoL are modifiable, indicating that patients with VTE could potentially benefit from interventions aimed at improving QoL.

Pulmonary Embolism Response Teams: Pursuing Excellence in the Care for Venous Thromboembolism

Acute pulmonary embolism remains a catastrophic acute cardiovascular event, and it is the leading cause of preventable mortality among hospitalized patients. Pulmonary embolism response teams have been designed to facilitate efficiency, streamline and improve quality of care in a timely manner for complex pulmonary embolism case scenarios with a multidisciplinary approach. Herein, we briefly describe and delineate the main goals and strategies on how to leverage the strengths from such pulmonary embolism response teams, with the aim to be adopted worldwide, improve survival, and change the paradigm in the care of a potentially deadly disease.

Gaps of care in patients with venous thrombotic embolism: a qualitative study.

Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT), and results in 100,000 deaths annually in the United States. There is low global VTE awareness, including limited data regarding difficulties patients encounter during their management. This study aims to identify a patient's perspective on VTE gaps of care. This is a qualitative study using semi-structured interviews with VTE patients, who had been previously diagnosed and treated for at least one VTE event in their lifetime. Participants were separated in five focused groups; sample size was defined by data saturation. Interviews were audio recorded, transcribed verbatim, and analyzed thematically using framework analysis based on data saturation evaluation. The study was approved by a local institutional review board. We used inductive framework analysis to interpret the data. Twenty participants were included in the analysis. Ten participants (50%) were men. Three major themes were identified: 1) concerned about limited disease knowledge; 2) VTE awareness in healthcare system; 3) incomplete communication during transitional and follow-up care. Findings suggest that gaps of VTE care extend in different levels of the medical system, including: the patient, physicians, and medical teams. Patients were sensitive to a lack of disease awareness among healthcare providers. There was appreciation for subspecialty care recommended for VTE. In a qualitative study, using the patient perspective, we have detected frustrations and perceived areas of improvement of the care of the patient with VTE. These gaps are anchored in perceived lack of disease awareness and difficult transitional care.

Understanding patients' care barriers in the treatment of venous thromboembolism.

Venous thromboembolism (VTE) is a major health care problem. There are common barriers to quality healthcare but are these barriers the same for VTE patients? A national online survey was administered to adults who had experienced a recent VTE event. The survey assessed perceptions of VTE care barriers: (1) Difficulty to meet healthcare costs related to VTE care; (2) difficulty to meet costs for VTE prescription medications; (3) difficulty with transportation to get VTE care; and (4) the degree of support of others needed to get VTE care. Each question was correlated with patient demographics including income level, place of residence, current work status, and health insurance; care related patient harms experienced with the VTE episode; number of lifetime VTE events; beliefs concerning VTE outcomes, and oral anticoagulant therapy type. Logistic regression analysis was used to determine the effect of independent variables on barriers to VTE care. Approximately 30% of VTE patients reported at least one significant barrier to VTE care. Patients rated healthcare costs and VTE prescription medication costs mildly difficult. The odds of reporting barriers were positively associated with the number of DVTs experienced in the previous 2years. VTE-related depression was also moderately associated with increased odds of reporting significant VTE care barriers. Nearly 1 in 3 VTE sufferers reported significant barriers to VTE care, with healthcare costs and VTE medication costs being the most common. Efforts to identify patients who may experience barriers should be sought early in care.

Patient Satisfaction With Venous Thromboembolism Treatment

Venous thromboembolism (VTE) represents a major health-care problem. Understanding patient satisfaction with VTE care is an important health-care goal. A national online survey was administered to adults who had experienced a recent VTE event. The survey assessed patient satisfaction by: (1) satisfaction with VTE care provider; (2) likelihood to recommend VTE provider; and (3) satisfaction with communication between VTE care providers. Each question was correlated with patient demographics, patient care harms (ie, misdiagnosis, wrong treatment), patient beliefs concerning outcomes, and type of anticoagulant therapy. Respondents (907) were 52.4 ± 14.4 years, predominantly Caucasian, mostly women, and generally had health insurance. Most respondents were satisfied with VTE care providers, likely to recommend their VTE provider, and satisfied with communication between providers. Dissatisfaction was strongly associated with treatment mistakes, a wrong diagnosis or treatment, or delayed treatment. A national sample of VTE patients were generally satisfied with VTE care experiences. The VTE care dissatisfaction was strongly associated with perceived mistakes in VTE care. Interventions aimed at reducing, acknowledging, and communicating errors could be studied to improve VTE care satisfaction.