Post-discharge Therapy Research Articles

Comparison of Antithrombotic Regimens after Left Atrial Appendage Occlusion: A Systematic Review and Network Meta-analysis

Abstract Background The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF) remains uncertain. Purpose This network meta-analysis aimed to compare the efficacy and safety of various antithrombotic strategies after LAAO. Methods We conducted a comprehensive search of MEDLINE, Cochrane, Embase, and ClinicalTrials.gov databases for studies that reported outcomes after LAAO, stratified by the antithrombotic therapies administered at discharge. Direct oral anticoagulants (DOACs), vitamin-K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random-effects model network meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CI) for each strategy. The surface under the cumulative ranking curve (SUCRA) P-scores provided a ranking of treatments. Quality assessment and risk of bias were conducted in accordance with Cochrane recommendations. Results We included 39 studies comprising 10,573 patients with non-valvular AF. As shown in Figure 1, in the network comparison, DAPT (OR 0.33; 95% CI 0.14-0.73), DOAC (OR 0.31; 95% CI 0.11-0.84), DOAC plus SAPT (OR 0.15; 95% CI 0.03-0.68), and VKA (OR 0.29; 95% CI 0.10-0.87) were superior to no therapy in preventing device-related thrombosis (DRT). There was no significant difference between the therapies analyzed in terms of major bleeding (Figure 2). In the SUCRA analysis, DOAC plus SAPT had the highest probability of being the best strategy for preventing DRT, followed by VKA and DOAC monotherapies, respectively. DOAC monotherapy was associated with the lowest probability of major bleeding, followed by DOAC plus SAPT and VKA as monotherapy, respectively. Conclusion In patients with non-valvular AF undergoing LAAO, post-discharge therapy with DOAC as monotherapy reduces the incidence of DRT compared with no therapy and is associated with a lower probability of major bleeding compared with other therapies.Figure 1.DRTFigure 2.Major bleeding

Outcome in TBI Patients with Early Physiotherapy and Post-discharge Rehabilitation: Indian Experience

Abstract Introduction Traumatic brain injury (TBI) is a major cause of death and disability worldwide and early initiation of physiotherapy with continuing rehabilitation may improve outcomes. Methods All adult TBI patients with GCS 5–12 admitted from May 2018 to December 2019 were included. Early physiotherapy was initiated before the fifth day of admission and continued post discharge. Patients and families were educated in a rehabilitation program with printed handouts and video clips. All patients are followed up via telephone/video calls after discharge. We assessed the Glasgow Outcome Score (GOS) and disability at 15, 30, and 90 days post discharge, and 180 days follow-up was also suggested but only a few (38) patients reported. Data were compared with matched patients treated in previous years. Results A total of 1,233 patients were studied. At 3-month follow-up by telephonic and video calls, GOS 5 was noted (63.7%; 174/ 273) in 2019 compared with (41.3%; 41/ 98) in 2018. The number of discharges increased after initiation of physiotherapy and rehabilitation programs (38%; 288/759 in 2019 versus 24%; 115/474 in 2018). Post-discharge deaths were also less (5.9%; 17/288) in 2019 compared with (14.8%; 17/115) in 2018. Conclusion Early rehabilitation and post-discharge therapy are associated with improved outcomes of TBI patients. Refinements in data collection and communication improve patient follow-up and functional outcomes.

Early antithrombotic post-discharge therapy using prophylactic DOAC or dipyridamole improves long-term survival and cardiovascular outcomes in hospitalized COVID-19 survivors.

IntroductionCardiovascular events are common in COVID-19. While the use of anticoagulation during hospitalization has been established in current guidelines, recommendations regarding antithrombotic therapy in the post-discharge period are conflicting.MethodsTo investigate this issue, we conducted a retrospective follow-up (393 ± 87 days) of 1,746 consecutive patients, hospitalized with and surviving COVID-19 pneumonia at a single tertiary medical center between April and December 2020. Survivors received either 30-day post-discharge antithrombotic treatment regime using prophylactic direct oral anticoagulation (DOAC; n = 1,002) or dipyridamole (n = 304), or, no post-discharge antithrombotic treatment (Ctrl; n = 440). All-cause mortality, as well as cardiovascular mortality (CVM) and further cardiovascular outcomes (CVO) resulting in hospitalization due to pulmonary embolism (PE), myocardial infarction (MI) and stroke were investigated during the follow-up period.ResultsWhile no major bleeding events occured during follow-up in the treatment groups, Ctrl showed a high but evenly distributed rate all-cause mortality. All-cause mortality (CVM) was attenuated by prophylactic DOAC (0.6%, P < 0.001) and dipyridamole (0.7%, P < 0.001). This effect was also evident for both therapies after propensity score analyses using weighted binary logistic regression [DOAC: B = −3.33 (0.60), P < 0.001 and dipyridamole: B = −3.04 (0.76), P < 0.001]. While both treatment groups displayed a reduced rate of CVM [DOAC: B = −2.69 (0.74), P < 0.001 and dipyridamole: B = −17.95 (0.37), P < 0.001], the effect in the DOAC group was driven by reduction of both PE [B−3.12 (1.42), P = 0.012] and stroke [B = −3.08 (1.23), P = 0.028]. Dipyridamole significantly reduced rates of PE alone [B = −17.05 (1.01), P < 0.001].ConclusionLate cardiovascular events and all-cause mortality were high in the year following hospitalization for COVID-19. Application of prophylactic DOAC or dipyridamole in the early post-discharge period improved mid- and long-term CVO and all-cause mortality in COVID-19 survivors.

Careggi Re-Engineered Discharge project: standardize discharge and improve care coordination between healthcare professionals

The hospital discharge process plays a key role for patient care. CaRED (Careggi Re-Engineered Discharge) aimed at establishing a meaningful relationship among General Practitioners (GPs) and patients, throughout the discharge process. In this paper we describe the activities and results in the period 2014 - 2017. CaRED is a restructured discharge protocol, which foresees a different, more direct form of communication between hospital and GPs, enabled by an ad-hoc electronic medical record. The 30-day hospital readmission rate and/or accesses to the emergency department were evaluated as proxy of effective communication. A pre-post survey was launched to assess the GPs' perceived quality, and patient and family satisfaction. A total of 1,549 hospitalizations were included, respectively 717 in the pre and 832 in the post intervention period. The 30-day hospital readmission rate decreased significantly in the post intervention period (14.4% vs 19.4%, χ2(1)=8.03, P<0.05).Eighty-two and 52 GPs participated, respectively, in the pre- and post- survey. In the post-phase the percentage of GPs declaring the discharge letter facilitated the communication on the admission causes (χ2(1)=0.56, P=0.03) and on what to do if conditions change (χ2(31)=19.0 P <0.01) significantly increased, as well as the perception of an easier contact with the hospitalist (χ2(3)=19.6, P <0.01).Two-hundred-eighty and 282 patients were enrolled in the pre- and post- survey. The level of understanding of key parts of the discharge letter (reason for hospitalization, post-discharge therapy, follow-up examinations and how to contact the hospital ward) improved significantly (P <0.01). CaRED significantly improved the discharge process, and became a benchmark for local improvements in communication patterns with GPs.

Abstract TP136: Disparities In Care Of Patients With Intracerebral Hemorrhage According To Baseline Functional Status

Introduction: Disparities exist in acute ischemic stroke care according to patients’ pre-stroke functional status. However, the effects of baseline disability on the presentation and care of patients with intracerebral hemorrhage (ICH) are unknown. We aimed to understand this using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study. Methods: We ascertained all hospitalized ICH patients ≥18 years old in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46 GCNK) population; all cases were physician-reviewed. Per-stroke functional status was ascertained by medical record review. Baseline NIHSS, Glasgow coma scale (GCS), imaging modalities (CT/MRI), in-hospital rehabilitative therapies (rate and frequency), initiation of antihypertensive treatment, and discharge disposition between patients with pre-ICH mRS 0-1 vs ≥2 were compared using Wilcoxon rank-sum or chi-square tests. Logistic regression was used to evaluate the association between pre-stroke mRS and in-hospital therapy, post-discharge therapy, and ICH workup adjusting for age, Glasgow score, insurance status, and ICH location. Results: Of 350 patients with ICH, 187 (53%) had a pre-ICH mRS ≥2. Compared to those with pre-stroke mRS 0-1, these patients had more severe clinical presentation as measured by NIHSS and GCS (table). Among patients who were not made comfort care, no association between pre-ICH mRS and performance of inpatient MRI or in-hospital and post-discharge rehabilitative therapies was found in adjusted analyses. Conclusions: Patients with pre-ICH mRS &gt;2 were made comfort care at a higher rate, but for those not made comfort care there were no post-ICH disparities of care seen in the 2015 GCNK population-based cohort of 350 patients.

Abstract 46: An Innovative Approach to the Bedside Nursing Swallow Screening Tool: Can Be Used as a Trigger for an Inpatient Cognitive Evaluation to Improve Timeliness of Post-Discharge Cognitive Therapy Referrals

Background: According to the American Heart Association, a formal assessment of cognitive dysfunction caused by stroke is a level I recommendation. However, cognitive evaluation is often missed or overlooked in the inpatient setting. When and who performs the assessment is not well-defined. Stroke nurses can corroborate with clinicians in completing the Montreal Cognitive Assessment (MoCA) 8.1, a validated tool for assessing cognitive function in stroke patients. Purpose: The purpose of this study was to evaluate the process of using the bedside nursing swallow screen (NSS) as a trigger for an inpatient cognitive evaluation by the Speech Therapist (ST). This study was also used to determine if post-discharge cognitive therapy referrals were placed based on the MoCA scores. Methods: All STs completed the required MoCA certification. The new process was implemented in October 2019. Data were analyzed from October 2019 through March 2020. NSS was performed on newly admitted stroke patients. If failed, an ST consult was ordered for a dysphagia evaluation. However, if passed, a cognitive evaluation consult was triggered by the RN. MoCA was completed within 24 hours. The total possible score is 30; a score of 26 or above is considered normal. A MoCA score of 25 or less, prompted a post-discharge cognitive therapy referral. Results: 229 patients were assessed, all of whom had an NSS completed. 120 (52.4%) passed the NSS, of which 85 (71%) completed a MoCA evaluation. 42 (49.4%) scored 25 or less, of which 35 (83.3%) were referred for a post-discharge cognitive therapy. 7 (17%) had no referral, of which 4 (57%) were discharged home to self-care; 2 (29%) discharged to other healthcare facility; and 1 (14%) left against medical advice. Conclusions: Repurposing the NSS as a standardized tool to trigger an inpatient MoCA evaluation was innovative, practical and efficient. Timely post-discharge cognitive therapy referrals were also evident on MoCA scores of 25 or less.

Therapy Discontinuation after Myocardial Infarction.

The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients. Material and methods: The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data. Results: Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42–18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45–16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y12 receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)—1.59; 95% CI 1.15–2.19; p = 0.0049) and prior revascularization (HR—1.44; 95% CI 1.04–2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications. Conclusions: The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation.

Inpatient and outpatient treatment patterns of cancer-associated thrombosis in the United States

Low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) are among the recommended treatment options for cancer-associated thrombosis (CAT) in the 2019 National Comprehensive Care Network guidelines. Little is known about the current utilization of DOACs in CAT patients, particularly on the inpatient to outpatient therapy transition. This study assessed real-world treatment patterns of CAT in hospital/ED in adult cancer patients (≥ 18 years) diagnosed with CAT during a hospital visit in IQVIA’s Hospital Charge Data Master database between July 1, 2015 and April 30, 2018, and followed their outpatient medical and pharmacy claims to evaluate the initial inpatient/ED and outpatient anticoagulants received within 3 months post-discharge. Results showed that LMWH and unfractionated heparin (UFH) were the most common initial inpatient/ED CAT treatments (35.2% and 27.4%, respectively), followed by DOACs (9.6%); 20.8% of patients received no anticoagulants. Most DOAC patients remained on DOACs from inpatient/ED to outpatient settings (71.4%), while 24.1%, 43.5%, and 0.1% of patients treated with LMWH, warfarin, or UFH respectively, remained on the same therapy after discharge. In addition, DOACs were the most common initial post-discharge outpatient therapy. Outpatient treatment persistence and adherence appeared higher in patients using DOACs or warfarin versus LMWH or UFH. This study shows that DOACs are used as an inpatient/ED treatment option for CAT, and are associated with less post-discharge treatment switching and higher persistence and adherence. Further research generating real-world evidence on the role of DOACs to help inform the complex CAT clinical treatment decisions is warranted.

Antecedent cancer in Takotsubo syndrome predicts both cardiovascular and long-term mortality

BackgroundTakotsubo syndrome (TTS), primarily an acute myocardial inflammatory condition engendered by catecholamine exposure, is associated with similar long-term mortality rates to those of patients with acute myocardial infarction. However, there is increasing evidence of a nexus between TTS and underlying malignancies:- many patients have antecedent cancer (A/Ca), while incremental risk of late cancer-related death has also been reported.PurposeTo evaluate potential interactions between A/Ca among TTS patients and both early and late clinical course.MethodsThree hundred forty-six consecutive TTS patients [aged 69 ± 13 (SD) years, males: 8.2%] were prospectively followed up for a median duration of 4.1 (IQR 2.2–6.4) years. Associations between A/Ca and severity of acute attacks, in-hospital complications and long-term death rates were sought utilising univariate analyses followed by multiple logistic regression analysis.ResultsA/Ca (present in 16.8% of patients) was associated with (i) greater elevation of hs-CRP and NT-proBNP concentrations (p = 0.01 and 0.04, respectively), (ii) more complicated in-hospital clinical course, with major adverse cardiac events (MACE) in 30.9% of patients, compared to 18.2% in non-A/Ca patients (p = 0.04). Long-term all-cause mortality rate was also greater [hazard ratio (HR) = 2.4, p = 0.0001] in A/Ca patients, with an excess cardiovascular (CVS) fatality rate (HR = 3.1, p = 0.001). On multivariate analysis, male gender, peak plasma concentrations of normetanephrine and hs-CRP, early arrhythmias and development of shock, but not A/Ca per se, were all independently associated with increased long-term mortality rate. Furthermore, patients discharged on β-adrenoceptor antagonists (βBl) or angiotensin converting enzyme inhibitors/ angiotensin receptor blockers (ACEi/ARB) had lower long-term mortality rates (β = − 0.2, p = 0.01; β = − 0.14, p = 0.05, respectively).Conclusions(1) A/Ca is associated with greater clinical severity of initial TTS attacks and substantially greater long-term CVS-related as well as all-cause mortality.(2) Post-discharge therapy with either βBl or ACEi/ARB is associated with reductions in long-term mortality rates.Overall, the current data suggest operation of substantial interactions between neoplasia and TTS, both at the level of pathogenesis and of outcomes.

P1764Quality criteria for STEMI care - a national perspective

Abstract Introduction The definition of quality criteria in health care is essential to implement structural organization strategies that ensure that patients (P) receive the best care according to the most updated recommendations available at the time they are treated. Quality indicators have recently been defined with regard to the approach and treatment of STEMI in the European Guidelines published in 2017. Objective The authors intend to characterize the level of care provided to P with STEMI inserted into a national multicenter registry since 2011 in order to establish a relationship with international recommendations. Population and methods Descriptive study based on a national multicenter registry. A total of 2051 P admitted to the hospital with the diagnosis of STEMI were included, 1266 P for the year 2011 and 785 P for the year 2016. Results The P of the year 2011 and 2016 presented similar age (64±14 vs 63±13). There was a higher percentage of P admitted by STEMI fast track managed care system in 2016 (36.9% vs 22.2%, p&lt;0,001) and less from the Emergency Department (31.6% vs 56.8%; p&lt;0,001). Regarding the transport to the Hospital, there was an increase in patients transported by prehospital medical teams (28% vs 21%; p&lt;0,001) and less by own means (35.7% vs 45.6%; p&lt;0,001). Regarding in-hospital therapy, it was found that in 2016 more patients received loading doses of P2Y12 inhibitors – Clopidogrel (78.1% vs 70.3% P&lt;0,001) and Ticagrelor (54.7% vs 0.7% P&lt;0,001). In post-discharge therapy, there was also a slight improvement in care in 2016, with more P being treated with P2Y12 inhibitor (96.2% vs 92.4%; p=0.03) and beta-blocker (84.4% vs 78.7%; p&lt;0,001). Regarding the type of reperfusion, there was an increase in angioplasty (95.5% vs 92.2%; p&lt;0,001) and a decrease in fibrinolysis (4.5% vs 7.8%; p=0.03) in 2016. There was a slight worsening of the prehospital delay in 2016 (median 163min vs 120min) and an improvement in door to reperfusion time (median 60min vs 70min). There was also an increase in angioplasties performed in 2016 (87.1% vs 85.1%; p&lt;0,001) as well as an increase in the percentage of left ventricular function evaluation before discharge (98.2% vs 93.9%; p&lt;0,001). Conclusion The results presented demonstrate a slight improvement in the quality of the care provided to STEMI P. However, there are areas for improvement, in accordance with international recommendations, in particular with regard to reperfusion times.

Abstract 3367: Treatment patterns in patients with cancer-associated venous thromboembolism in the US: A real world retrospective database analysis

Abstract Background: Cancer patients have higher risk of venous thromboembolism (VTE) due to the cancer-induced hypercoagulable state or activation of the coagulation cascade by chemotherapy. The 2018 National Comprehensive Cancer Network guidelines recommend low molecular weight heparin (LMWH) to treat cancer-associated VTE and direct oral anticoagulants (DOACs) in some circumstances. This study aimed to understand VTE treatment patterns in a cancer-associated VTE population during hospitalization and post-discharge. Methods: Patients with cancer-associated VTE and their respective treatments were identified in IQVIA’s hospital Charge Data Master database from 7/1/15 to 4/30/18. Patients were followed for 1 month after VTE hospitalization. Post-discharge therapy was obtained from outpatient medical and pharmacy claims data. Results: A total of 5,920 cancer patients hospitalized for VTE (54% female; mean age 65.9 [SD=13.0] years) were included. Lung (20%) and breast (13%) cancers were the most common cancer types. Average length of stay was 5.3 days (SD=4.1). 5,366 (91%) patients were treated during the hospital stay; LMWH (51%), DOACs (15%) and warfarin (12%) were the most common inpatient treatments. Within 30 days after discharge, the most common treatments were DOACs (26%) and LMWH (16%); 2,858 (48%) had no observed treatment in the outpatient setting. After discharge, 1,272 (21%) patients remained on the same therapy and 1,436 (24%) switched to a new treatment. Among those patients initiating DOACs (N=865) during hospitalization, 46% remained on DOACs after discharge. Conclusions: In US hospital and outpatient settings, this real world study showed that LMWH treatment and treatment with DOACs were the most common initial inpatient therapies for cancer-associated VTE. DOACs were the most common post discharge treatment. Further investigation of patients without continued treatment within 30 days of discharge is warranted. Distribution of post-discharge VTE therapy by initial VTE observed during index hospitalizationInitial VTE therapy during hospitalization(n=5,920)Post-Discharge VTE TherapyLMWH(n=918)Heparin(n=12)Warfarin(n=560)DOAC(n=1,561)Thrombolytic Agent (n=11)No post-discharge VTE treatment(n=2,858)LMWH n=3,040; 51.4%648 (21.3%)6 (0.2%)213 (7.0%)678 (22.3%)6 (0.2%)1,489 (49.0%)Heparin n=566; 9.6%48 (8.5%)2 (0.4%)34 (6.0%)166 (29.3%)1 (0.2%)315 (55.7%)Warfarin n=685; 11.6%80 (11.7%)2 (0.3%)242 (35.3%)86 (12.6%)2 (0.3%)273 (39.9%)DOAC n=865; 14.6%25 (2.9%)0 (0.0%)13 (1.5%)400 (46.2%)1 (0.1%)426 (49.2%)Thrombolytic agent n=210; 3.5%36 (17.1%)1 (0.5%)13 (6.2%)50 (23.8%)1 (0.5%)109 (51.9%)No initial VTE treatment n=554; 9.4%81 (14.6%)1 (0.2%)45 (8.1%)181 (32.7%)0 (0.0%)246 (44.4%)* Patients with no treatment within 30 days after hospital discharge were censored at 30-days post-dishcarge Citation Format: Jennifer D. Guo, Patrick Hlavacek, Tayla Poretta, Gail Wygant, Daniel C. Lane, Magdaliz Gorritz, Xin Wang, Chi-Chang Chen, Xianying Pan, Lisa Rosenblatt. Treatment patterns in patients with cancer-associated venous thromboembolism in the US: A real world retrospective database analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3367.

Abstract 263: Real World Outpatient Treatment Patterns of Patients with Cancer-Associated Venous Thromboembolism in the US

Objective: The aim of the study is to describe post-discharge treatment patterns in patients with cancer-associated venous thromboembolism (VTE) following an emergency department (ED) visit or inpatient (IP) admission. Methods: Adults (≥ 18 years) with VTE diagnosed during an ED or IP visit with a cancer diagnosis, and their respective VTE treatments were identified from the IQVIA Real-World Data Adjudicated Claims - US TM database between 7/1/15 and 6/30/17. Initial outpatient (OP) treatment received within 6 months post-discharge was assessed. Treatment duration, adherence, persistence, and switching were evaluated over variable follow-up in patients who had ≥ 6 months of continuous health plan eligibility after initiation of OP therapy. Results: A total of 3,064 cancer-associated VTE patients (54% female; mean age 54.3 [SD=9.9] years) were included. 53% were diagnosed with VTE in the ED and 47% IP. The most common initial post-discharge OP treatments observed were direct-acting oral anti-coagulants (DOACs; 37%), low molecular weight heparin (LMWH; 30%), and warfarin (12%); 10% of patients had no evidence of treatment within 6-months of discharge. Median follow-up after treatment initiation was 412 days among the 2,698 patients who had at least 6 months of follow-up after initiation of post-discharge therapy. Duration of treatment (allowable gap=60 days) was longest with DOACs (231.5 days [SD=183.1]), followed by warfarin (223.0 days [SD=200.0] and LMWH (138.3 days [SD=138.2]. Adherence to initial treatment prior to discontinuation was high across all therapies, with 80% of patients having a medication possession ratio (MPR) ≥ 80%. The proportion of patients who remained on therapy for ≥ 6 months was highest among patients who initiated DOACs (55%), followed by warfarin (51%) and LMWH (33%) patients. A total of 1,597 (59%) patients discontinued their initial post-discharge treatment within 6 months of initiation, with an average time to discontinuation of 87.5 days (SD=53.4) for DOACs, 76.7 days (SD=51.6) for warfarin patients, and 61.3 days (SD=49.3) for LMWH. Among these, 30%, 54%, and 65% of DOAC, warfarin, and LMWH patients, respectively, switched to a new OP treatment. Patients who initiated OP therapy with DOACs were most likely to switch to LMWH (33%) or warfarin (21%), while those who initiated therapy with warfarin or LMWH were most likely to switch to DOACs after discontinuation (74% and 70%, respectively). Conclusions: This real-world study showed that DOACs or LMWH were the most common initial post-discharge therapies for cancer-associated VTE. Although treatment adherence was high, only DOAC and warfarin patients had a 6-month persistence rate on initial treatment ≥ 50%. Switching was most common in patients treated with warfarin or LMWH, most of whom switched to DOACs.

Exploring variation in patient access of post-discharge physiotherapy following total hip and knee arthroplasty under a choice based system in the UK: an observational cohort study

ObjectivesTo assess a targeted ‘therapy as required’ model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total...

Building a Bridge Between Primary and Perioperative Care: Addressing the Challenges of Perioperative Buprenorphine Maintenance and Postdischarge Therapy.

As awareness of the opioid use disorder epidemic has increased, the number of people on rehabilitative medication–assisted treatment has seen a concurrent rise. Buprenorphine, available in multiple preparations, plays an important role in opioid detoxification, addiction therapy, and chronic pain

Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach.

OBJECTIVE For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Postdischarge therapy is often unnecessarily broad spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. DESIGN Single center, quasi-experimental retrospective cohort study METHODS Patients prescribed oral antibiotics at hospital discharge before (July 2012-June 2013) and after (October 2014-February 2015) an intervention consisting of (1) institutional guidance for oral step-down antibiotic selection and duration of therapy and (2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The primary outcomes measured were total prescribed duration of therapy and use of antibiotics with broad gram-negative activity (ie, fluoroquinolones or amoxicillin-clavulanate). RESULTS Overall, 300 cases from the preintervention period and 200 cases from the intervention period were included. Compared with the preintervention period, the use of antibiotics with broad gram-negative activity decreased during the intervention (51% vs 40%; P=.02), particularly fluoroquinolones (38% vs 25%; P=.002). The total duration of therapy decreased from a median of 10 days (interquartile range [IQR], 7-13 days) to 9 days (IQR, 6-13 days) but did not reach statistical significance (P=.13). However, the duration prescribed at discharge declined from 6 days (IQR, 4-10 days) to 5 days (IQR, 3-7 days) (P=.003). During the intervention, there was a nonsignificant increase in the overall appropriateness of discharge prescriptions from 52% to 66% (P=.15). CONCLUSIONS A multifaceted intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of antibiotics with broad gram-negative activity and shorter postdischarge treatment durations. Infect Control Hosp Epidemiol 2017;38:534-541.

Neurologic Functional and Quality of Life Outcomes after TBI: Clinic Attendees versus Non-Attendees.

This investigation describes the relationship between TBI patient demographics, quality of life outcome, and functional status outcome among clinic attendees and non-attendees. Of adult TBI survivors with intracranial hemorrhage, 63 attended our TBI clinic and 167 did not attend. All were telephone surveyed using the Extended-Glasgow Outcome Scale (GOSE), the Quality of Life after Brain Injury (QOLIBRI) scale, and a post-discharge therapy questionnaire. To determine risk factors for GOSE and QOLIBRI outcomes, we created multivariable regression models employing covariates of age, injury characteristics, clinic attendance, insurance status, post-discharge rehabilitation, and time from injury. Compared with those with severe TBI, higher GOSE scores were identified in individuals with both mild (odds ratio [OR]=2.0; 95% confidence interval [CI]: 1.1-3.6) and moderate (OR=4.7; 95% CI: 1.6-14.1) TBIs. In addition, survivors with private insurance had higher GOSE scores, compared with those with public insurance (OR=2.0; 95% CI: 1.1-3.6), workers' compensation (OR=8.4; 95% CI: 2.6-26.9), and no insurance (OR=3.1; 95% CI: 1.6-6.2). Compared with those with severe TBI, QOLIBRI scores were 11.7 points (95% CI: 3.7-19.7) higher in survivors with mild TBI and 17.3 points (95% CI: 3.2-31.5) higher in survivors with moderate TBI. In addition, survivors who received post-discharge rehabilitation had higher QOLIBRI scores by 11.4 points (95% CI: 3.7-19.1) than those who did not. Survivors with private insurance had QOLIBRI scores that were 25.5 points higher (95% CI: 11.3-39.7) than those with workers' compensation and 16.8 points higher (95% CI: 7.4-26.2) than those without insurance. Because neurologic injury severity, insurance status, and receipt of rehabilitation or therapy are independent risk factors for functional and quality of life outcomes, future directions will include improving earlier access to post-TBI rehabilitation, social work services, affordable insurance, and community resources.

Adherence to antiplatelet therapy after percutaneous coronary intervention: a population study in a region of Italy.

We evaluated adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for patients in the Lazio region of Italy and the impact of discharge ward type on therapy discontinuation. From the Hospital Information System, we selected patients who underwent PCI from 2006 to 2007 and obtained Regional Drug Dispense Registry data for antiplatelet drugs prescribed for 12 months after discharge. Appropriate therapy was defined as DAPT with prescribed daily doses for each drug covering at least 75% of each individual follow-up period. The association between discharge ward type and antiplatelet therapy adherence at 12 months post discharge was estimated using multilevel logistic regression analysis. A total of 11 186 patients with PCI were included, and fewer than half (4984; 44.56%) were on adequate DAPT. Only 2930 of 5390 patients (54.36%) with DAPT in the first 6 months post discharge continued DAPT in the second 6 months. Patients discharged from cardiology units or intensive coronary care units were more likely (odds ratio = 1.26; P = 0.003) to receive appropriate antiplatelet therapy, and elderly patients were less likely (odds ratio = 0.65; P < 0.001) to do so. The proportion of PCI patients receiving appropriate DAPT after discharge is suboptimal in this region, and elderly patients are less likely to receive appropriate therapy. These findings could be important for improving patient management and ensuring adherence to clinical guidelines and indicate the need for a systematic evaluation of the appropriateness of postdischarge therapy.

Statin treatment and intracerebral hemorrhage prognosis

Sir, We read with great interest in the study of Tapia-Perez et al. [3] the positive effects of continuous statin treatment on patients after acute intracerebral hemorrhage (ICH). With respect to the delightful effects of statin on acute ICH patients, we have three things in comment. First, although some small sample-sized retrospective observation studies find that continuous statin treatment may have better short-term outcomes in acute ICH patients [2], a larger sample-sized study which analyzes 2,466 consecutive ICH patients finds no association between statin and prognoses or mortality after acute ICH [1]. In fact, the authors also conclude that even though the discontinuation of statin is associated with poor prognoses and higher mortality, the association becomes so weak and no longer significant after excluding patients needing palliative care, who basically have poorer health than other subjects in the study. Therefore, back to the study of Tapia-Perez et al. in discussion, we are curious whether the positive outcomes of statin treatment of the intervention group result from the relatively healthier population in this very group or not, who could tolerate the ordinary medication as well as statin treatment, while the subjects in the non-statin-treated group are basically too ill to stick to the ordinary medication including statin. Second, the values of the study of Tapia-Perez et al. are the consistent measurement and comparison of leucocyte count and C-reactive protein (CRP) level during the trial period. However, it is arbitrary to attribute the effects of better anti-inflammatory to the statin therapy in statintreated group because when comparing with the nonstatin-treated group, the CRP level is only significantly lower in the first 24 h after acute ICH in the statin-treated group, and the physiological outcome does not persist long in day 3 and day 7 after acute ICH. Therefore, there must be some unrecognized factors that affect the physiological outcomes and drug effects, for example, the socioeconomic status, adherence to the post-discharge therapy, and aggressiveness of treatment. However, if the authors can reveal more anthropology information of the study population, it would be much more helpful in determining the influencing factors for physiological outcomes and prognoses. Third, lobar ICH accounts for nearly half (48.2 %) of the statin-treated ICH group in the study of Tapia-Perez et al. [3]. With regard to the statin treatment in lobar ICH patients, one recent study applies decision-analytic approach and suggests that statin should be avoided particularly in lobar ICH patients for its higher risk of recurrent hemorrhage and shorter life expectancy which is estimated at least 2.2 quality-adjusted life-years [4]. The results of no recurrent hemorrhage and decreased mortality at 3 and 6 months in the statin-treated group in the study of Tapia-Perez et al. are somehow impressive. Nevertheless, we suggest that longer follow-up period which exceeded at least 2 years may be necessary for evaluating long-term benefits of statin treatment.

Pharmacokinetics, Pharmacodynamics and Clinical Use of Valganciclovir in Newborns with Symptomatic Congenital Cytomegalovirus Infection

Congenital cytomegalovirus infection is the most common cause of nonhereditary sensorineural hearing loss and an important cause of psychomotor retardation. Newborns suffering from symptomatic congenital cytomegalovirus infection have been typically treated with i.v. ganciclovir (GCV). Nowadays valganciclovir (V-GCV), a mono-valyl ester pro-drug of GCV, is available as an oral syrup. The existing literature demonstrated that V-GCV is well absorbed from the gastrointestinal tract and is rapidly converted into GCV in the intestinal wall and liver. The mechanism of antiviral action is the same that has been described for GCV. All these characteristics make this formulation particularly suitable for the symptomatic congenitally infected newborns. In neonates, V-GCV oral formulation proved stable and constant GVC plasma concentrations, in the suggested therapeutic range. The syrup demonstrated to be clinically effective and well tolerated and to be appropriate for a prolonged post-discharge therapy avoiding the discomfort of hospitalization, reducing the risk for nosocomial infections and decreasing the cost for the National Health Service. This article reviews all the available literature about V-GCV syrup in the treatment of newborns and infants with congenital CMV infection with the regard to pharmacokinetics, pharmacodynamic properties and clinical use, focussing on new data and on our experience.

High platelet reactivity – the challenge of prolonged anticoagulation therapy after ACSI

Despite dual antiplatelet therapy (DAPT), one-year event rates after acute coronary syndrome (ACS) vary from 9-12%. The development of novel oral anticoagulants (NOAC) without a need for monitoring has initiated renewed interest for prolonged adjunctive anticoagulation. Importantly, the cornerstone of treatment after ACS consists of long-term DAPT. In that context, the NOACs have only been tested as adjunctive therapy. Of all new agents, only rivaroxaban -in a substantially lower dose than used for atrial fibrillation- has been demonstrated to improve outcome, albeit at the cost of bleeding. In selected cases, adjunctive therapy with dose-adjusted vitamin-K antagonists (international normalized ratio [INR] 2.0-3.0) can be considered as well. These two strategies of prolonged anticoagulation can be considered in case of 'high platelet reactivity', i.e. in patients at high risk of recurrent thrombotic events despite DAPT. Both during admission and after discharge for ACS, the use of NOACs in doses indicated for atrial fibrillation is strictly contra-indicated in patients on DAPT. In case of post-discharge anticoagulation therapy for atrial fibrillation, patients should preferably receive vitamin-K antagonists (INR 2.0-3.0), with discontinuation of one antiplatelet agent as soon as clinically justifiable. Importantly, the impact of prolonged anticoagulation (low-dose rivaroxaban, vitamin-K antagonists) as adjunctive to DAPT after ACS has not been addressed with the most potent antiplatelet agents (prasugrel, ticagrelor) and merits further study. Despite the potential indication of prolonged oral anticoagulation as adjunctive treatment, it remains to be established whether anticoagulation therapy could also be an alternative for either aspirin or thienopyridine treatment in selected ACS patients on DAPT.