Hospitalization For Medical Illness Research Articles

Clinical outcomes associated with anti-Xa-monitored enoxaparin for venous thromboembolism prophylaxis.

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. Retrospective cohort study. Hospital within an academic healthcare system. Propensity score-matched hospitalized adults receiving enoxaparin for VTE prophylaxis. Low-molecular-weight heparin anti-Xa monitoring. 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. 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.

Provider perceptions of extended venous thromboembolism prophylaxis for hospitalized medically ill patients

BackgroundAlmost one-fourth of medically ill patients may remain at risk for venous thromboembolism (VTE) following hospital discharge, yet few receive extended-duration VTE prophylaxis. MethodsThis qualitative study at a single academic medical center assessed hospitalists’ perceptions of and barriers to implementation of extended-duration VTE prophylaxis following hospital discharge for the medically ill with the purpose of generating topics and hypotheses for future study. A focus group was conducted using semi-structured facilitator template to guide the discussion. Anonymous verbatim data transcribed from focus group participants were summarized using thematic analysis. ResultsFifteen hospitalist providers at University of Utah Hospital participated in this focus group. Themes uncovered during the session included perceived low burden of post-hospitalization VTE; lack of compelling evidence supporting the net clinical benefit of extended-duration prophylaxis; concern for high medication cost; practical uncertainty about prescribing extended-duration prophylaxis; and added risk of complications (bleeding events, transitions of care confusion, polypharmacy). ConclusionsThis group of providers believed post-hospitalization VTE risk in the medically ill is not sufficiently high to justify potential risks of extended-duration VTE prophylaxis and that a strong case for net clinical benefit and cost-effectiveness has not been made. These qualitative data are hypothesis-generating and future research should clearly define and quantify the timing and risk of VTE following hospitalization for medical illness in a real-world population, validate practical VTE and bleeding risk stratification schema, and explore cost-effectiveness of extended-duration prophylaxis. Ultimately, providers seek a clear message of which patients derive net clinical benefit from extended-duration VTE prophylaxis.

Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study.

To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization. Prospective cohort study. New Haven, Connecticut. A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge. Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month. Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization. Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020.

Extended prophylaxis for venous thromboembolism after hospitalization for medical illness: A trial sequential and cumulative meta-analysis.

BackgroundThe efficacy, safety, and clinical importance of extended-duration thromboprophylaxis (EDT) for prevention of venous thromboembolism (VTE) in medical patients remain unclear. We compared the efficacy and safety of EDT in patients hospitalized for medical illness.Methods and findingsElectronic databases of PubMed/MEDLINE, EMBASE, Cochrane Central, and ClinicalTrials.gov were searched from inception to March 21, 2019. We included randomized clinical trials (RCTs) reporting use of EDT for prevention of VTE. We performed trial sequential and cumulative meta-analyses to evaluate EDT effects on the primary efficacy endpoint of symptomatic VTE or VTE-related death, International Society on Thrombosis and Haemostasis (ISTH) major or fatal bleeding, and all-cause mortality. The pooled number needed to treat (NNT) to prevent one symptomatic or fatal VTE event and the number needed to harm (NNH) to cause one major or fatal bleeding event were calculated.Across 5 RCTs with 40,247 patients (mean age: 67–77 years, proportion of women: 48%–54%, most common reason for admission: heart failure), the duration of EDT ranged from 24–47 days. EDT reduced symptomatic VTE or VTE-related death compared with standard of care (0.8% versus 1.2%; risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.44–0.83; p = 0.002). EDT increased risk of ISTH major or fatal bleeding (0.6% versus 0.3%; RR: 2.04, 95% CI: 1.42–2.91; p < 0.001) in both meta-analyses and trial sequential analyses. Pooled NNT to prevent one symptomatic VTE or VTE-related death was 250 (95% CI: 167–500), whereas NNH to cause one major or fatal bleeding event was 333 (95% CI: 200–1,000). Limitations of the study include variation in enrollment criteria, individual therapies, duration of EDT, and VTE detection protocols across included trials.ConclusionsIn this systematic review and meta-analysis of 5 randomized trials, we observed that use of a post-hospital discharge EDT strategy for a 4-to-6-week period reduced symptomatic or fatal VTE events at the expense of increased risk of major or fatal bleeding. Further investigations are still required to define the risks and benefits in discrete medically ill cohorts, evaluate cost-effectiveness, and develop pathways for targeted implementation of this postdischarge EDT strategy.Trial registrationPROSPERO CRD42018109151.

In at-risk medical patients, rivaroxaban after discharge did not reduce symptomatic or fatal VTE at 45 days.

Source Citation Spyropoulos AC, Ageno W, Albers GW, et al; MARINER Investigators. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Engl J Med. 2018;379:1118-27. 30145946

Glucagon orchestrates stress-induced hyperglycaemia.

Hyperglycaemia is commonly observed on admission and during hospitalization for medical illness, traumatic injury, burn and surgical intervention. This transient hyperglycaemia is referred to as stress‐induced hyperglycaemia (SIH) and frequently occurs in individuals without a history of diabetes. SIH has many of the same underlying hormonal disturbances as diabetes mellitus, specifically absolute or relative insulin deficiency and glucagon excess. SIH has the added features of elevated blood levels of catecholamines and cortisol, which are not typically present in people with diabetes who are not acutely ill. The seriousness of SIH is highlighted by its greater morbidity and mortality rates compared with those of hospitalized patients with normal glucose levels, and this increased risk is particularly high in those without pre‐existing diabetes. Insulin is the treatment standard for SIH, but new therapies that reduce glucose variability and hypoglycaemia are desired. In the present review, we focus on the key role of glucagon in SIH and discuss the potential use of glucagon receptor blockers and glucagon‐like peptide‐1 receptor agonists in SIH to achieve target glucose control.

Cancer and coagulation.

Thromboembolism, including both venous and arterial events, occurs commonly amongst patients with cancer. The occurrence of thromboembolism has significant consequences for cancer patients, including direct and indirect associations with mortality, morbidity, requirement for long-term anticoagulant therapy and consumption of healthcare resources. Recent studies have resulted in a better understanding of clinical risk factors and biomarkers of cancer-associated thrombosis, and a risk assessment model incorporating both has now been validated in multiple settings. Thromboprophylaxis with either unfractionated heparin or low-molecular-weight heparins (LMWHs) has been shown to be safe and effective in high-risk settings such as hospitalization for medical illness and the postsurgical period. Emerging new data from randomized studies have focused on outpatient prophylaxis, suggesting potential benefits in this setting as well. Treatment of cancer-associated thrombosis requires long-term anticoagulation with LMWH. Results from ongoing and planned trials of novel anticoagulants in the cancer setting are awaited.

Abstract 8642: A Randomized Controlled Trial of Physician Alerts to Prevent Symptomatic Venous Thromboembolism after Hospital Discharge

Introduction: Many patients develop venous thromboembolism (VTE) in the months following hospitalization for medical illness. Hypothesis: We assessed the hypothesis that a VTE prophylaxis alert from a hospital staff member to the Attending Physician prior to patient discharge from the hospital will reduce the incidence of symptomatic VTE after discharge. Methods: We enrolled hospitalized Medical Service patients in a large multicenter randomized controlled trial using a validated point score system to identify those at high risk for symptomatic VTE who were not ordered to receive VTE prophylaxis after discharge. Results: Among 2,513 eligible patients randomized from 18 study sites, 1,252 were assigned to the intervention group, and 1,261 were assigned to the control group. Patients in the intervention group were more than twice as likely to receive VTE prophylaxis at discharge as controls (22.0% versus 9.7%, p&lt;0.0001). Symptomatic VTE at 90 days (99.9% follow-up) occurred in 4.5% of patients in the intervention group compared with 4.0% of controls (hazard ratio, 1.12; 95% confidence interval, 0.74 to 1.69). Rates of death at 90 days and major bleeding at 30 days in the intervention group were similar to that of the control group. In an on-treatment analysis, we observed a nearly one-third reduction in 90-day mortality among at-risk medical patients whose physicians were alerted and in whom discharge prophylaxis was prescribed compared with those in whom the alert recommendation was not followed and compared with those for whom an alert was not issued and prophylaxis was not ordered after hospital discharge. Conclusion: We observed no difference in the rate of symptomatic VTE in patients assigned to the alert group compared with controls. The physician alert doubled the rate of VTE prophylaxis ordered at the time of hospital discharge. Further Quality Improvement initiatives to improve VTE prevention after hospital discharge are warranted.

Risk Factors for Venous Thromboembolism (VTE) Among Nursing Home Residents: A Population-Based Case Control Study

AbstractAbstract 476 Background:The burden of VTE among nursing home (NH) residents is known to be high. Yet very little data exist to help determine which NH residents to target for VTE prophylaxis. The need to characterize VTE risk in this population is especially great because the advanced age and high comorbidity that typify NH residents contribute to increased likelihood of adverse consequences from VTE prophylaxis. To compound the problem, results of our prior univariate analyses of certain factors known to contribute substantially to VTE risk in the general population (e.g., major surgery, medical hospitalization, trauma) suggest that impact of these factors on VTE may be less substantial among NH residents. Objective:To use the longitudinal population-based resources of the Rochester Epidemiology Project (REP) to investigate the contribution of multiple clinical characteristics to risk of VTE among NH residents. Methods:We took advantage of the previous identification of all Olmsted County, MN residents who met research criteria for incident VTE 1988 through 2005 (N=2,332). We then determined which individuals were resident of a local NH at time of VTE symptom onset, regardless of location of symptom onset (i.e., individuals whose VTE occurred in-hospital having been admitted from a NH were considered NH residents). For each such NH VTE case (N=269), we identified 2 same sex Olmsted County residents of similar age and duration of medical history who were also resident of a local NH at the time of the case's VTE event (i.e., index date) (N=538). We reviewed the detailed provider-linked medical records of NH VTE cases and NH non-VTE controls for 3 months before index for information on multiple characteristics identified or hypothesized as contributing to VTE risk in studies of the general population and other at-risk subgroups by our group and others (e.g., patient demographics, body mass index, major surgery, hospitalization for acute medical illness, outpatient surgical procedures, trauma/fracture, leg paresis, active cancer, superficial vein thrombosis, varicose veins, infections, diabetes mellitus, coronary artery disease, congestive heart failure, and multiple medications, including anticoagulants, statins, beta-blockers, ACE inhibitors and angiotensin II receptor antagonists). We tested and estimated the odds ratio associated with each factor using step-wise conditional logistic regression. Variables for which <10 cases or <10 controls exhibited the characteristic were excluded from analysis. Results:The first five variables to enter the model were urinary tract infection, active cancer, superficial vein thrombosis, pneumonia, and leg paresis. The respective odds ratios (95% confidence intervals) with all five in the model were 1.7 (1.2, 2.4); 2.1 (1.3, 3.5); 2.1 (1.3, 3.4); 1.9 (1.3, 2.8); 2.3 (1.3, 4.2); each p value was <0.01. Variables associated with high VTE risk in the general population (i.e., surgery, hospitalization for medical illness, trauma/fracture) were not included in the top five risk factors for NH residents. Conclusions:Infection is a potent VTE risk factor among NH residents. Our study results will help inform development of practice guidelines in the NH and stimulate future research on putative VTE mechanisms. REP data afford limited information on cognitive and physical disability, immobility, and need for NH care. Additional investigations are needed that combine information from clinical and NH assessments. Disclosures:No relevant conflicts of interest to declare.

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. Observational. Tertiary care hospital, community teaching hospital. Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998). Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.

New Walking Dependence Associated With Hospitalization for Acute Medical Illness: Incidence and Significance

The ability to walk independently may become jeopardized during hospitalization. It is unknown which patients are at risk for decline in walking, or to what extent patients will recover. The purpose of this study was to determine the incidence of, risk factors for, and outcomes associated with new walking dependence after hospitalization. Baseline characteristics and functional outcomes at hospital discharge and 3 months after discharge were measured for 1,181 community-dwelling adults aged 70 and over who were hospitalized for medical illness and who walked independently prior to hospitalization. At discharge, 16.8% of patients were newly dependent in walking. Risk factors included age > 85 (odds ratio [OR] 2.7 vs age <75, 95% confidence interval [CI] 1.5-4.9), functional impairment before hospitalization (OR 1.4 for each impairment, CI 1.1-1.7), Caucasian race (OR 1.9, CI 1.1-3.3), and use of a walker (OR 1.8, CI 1.04-3.2) or wheelchair (OR 3.2, CI 1.3-7.6) before admission. A cancer diagnosis (OR 2.3, CI 1.2-4.6) and more than four comorbid conditions (OR 1.9, CI 1.2-3.0) were also predictive. New walking dependence was associated with discharge to a nursing home (p = .0001) and higher postdischarge mortality (p < .001). Twenty-seven percent of patients who developed new walking dependence and survived 3 months continued to be dependent in walking. New walking dependence occurs frequently with hospitalization, may be predicted by specific risk factors, and portends a poor prognosis. Strategies are needed to help at-risk patients maintain walking independence during and after hospitalization.

Risk factors for nursing home use after hospitalization for medical illness.

Hospitalization, a sentinel event for many older persons, may mark a transition from independent living to either community-based or institutionalized long-term care. We determined the independent risk factors, including loss of function, of nursing home (NH) admission at hospital discharge and NH use at 3 months after hospital discharge among a diverse group of hospitalized older persons. The subjects in this study were 1,265 noninstitutionalized persons from phase II of Hospital Outcomes Project for the Elderly. Using multiple logistic regression, we modeled NH admission with variables measured at the time of hospital admission as well as with length of stay (LOS) and decline in ADL independence from hospital admission to discharge. In addition, we modeled NH use at 3 months after hospital discharge with variables measured at the time of hospital discharge as well as with post-hospital measures of rehospitalization and decline in ADL independence following hospitalization. The independence risk factors of NH placement at discharge are geographic site, increasing age, living alone, and low baseline ADL independence, LOS, and decline in ADL independence during hospitalization. The independent predictors for NH use at 3-month follow-up are increasing age, living alone, mental status, low discharge ADL independence, LOS, and decline in ADL independence during the 3 months after discharge. Simple but different clinical variables predict NH use at hospital discharge and at 3 months. Furthermore, functional loss during and after hospitalization is an important independent risk factor of nursing home use and is a clinical outcome that may be modified to decrease the likelihood of NH admission.