Although warfarin and other anticoagulants can prevent ischemic events, they can cause hemorrhage. Quantifying the rate of hemorrhage is crucial for determining the risks and net benefits of ...prescribing antithrombotic therapy. Our objective was to find a bleeding classification scheme that could quantify the risk of hemorrhage in elderly patients with atrial fibrillation.
We combined bleeding risk factors from existing classification schemes into a new scheme, HEMORR
2HAGES, and validated all bleeding classification schemes. We scored HEMORR
2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors:
hepatic or renal disease,
ethanol abuse,
malignancy, older (age > 75 years),
reduced platelet count or function,
hypertension (uncontrolled),
anemia,
genetic factors,
excessive fall risk, and
stroke. We used data from quality improvement organizations representing 7 states to assemble a registry of 3791 Medicare beneficiaries with atrial fibrillation.
There were 162 hospital admissions with an
International Classification of Diseases, Ninth Revision, Clinical Modification code for hemorrhage. With each additional point, the rate of bleeding per 100 patient-years of warfarin increased: 1.9 for 0, 2.5 for 1, 5.3 for 2, 8.4 for 3, 10.4 for 4, and 12.3 for ≥5 points. In patients prescribed warfarin, HEMORR
2HAGES had greater predictive accuracy (
c statistic 0.67) than other bleed prediction schemes (
P < .001).
Adaptations of existing classification schemes, especially a new bleeding risk scheme, HEMORR
2HAGES, can quantify the risk of hemorrhage and aid in the management of antithrombotic therapy.
Objectives: We sought to determine which ICD-9-CM codes in Medicare Part A data identify cardiovascular and stroke risk factors. Design and Participants: This was a cross-sectional study comparing ...ICD-9-CM data to structured medical record review from 23,657 Medicare beneficiaries aged 20 to 105 years who had atrial fibrillation. Measurements: Quality improvement organizations used standardized abstraction instruments to determine the presence of 9 cardiovascular and stroke risk factors. Using the chart abstractions as the gold standard, we assessed the accuracy of ICD-9-CM codes to identify these risk factors. Main Results: ICD-9-CM codes for all risk factors had high specificity (>0.95) and low sensitivity (≤0.76). The positive predictive values were greater than 0.95 for 5 common, chronic risk factors-coronary artery disease, stroke/transient ischemic attack, heart failure, diabetes, and hypertension. The sixth common risk factor, valvular heart disease, had a positive predictive value of 0.93. For all 6 common risk factors, negative predictive values ranged from 0.52 to 0.91. The rare risk factors-arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis-had high negative predictive value (≥0.98) but moderate positive predictive values (range, 0.54-0.77) in this population. Conclusions: Using ICD-9-CM codes alone, heart failure, coronary artery disease, diabetes, hypertension, and stroke can be ruled in but not necessarily ruled out. Where feasible, review of additional data (eg, physician notes or imaging studies) should be used to confirm the diagnosis of valvular disease, arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis.
Abstract Background Preoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain ...uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery. Methods We performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality. Results There were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio HR 3.91; confidence interval CI, 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia HR 4.39, mild anemia HR 2.27, and moderate/severe anemia HR 0.81; P for trend .0015). Conclusions Preoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted.
Does Public Reporting Improve Care? Radford, Martha J., MD
Journal of the American College of Cardiology,
03/2016, Volume:
67, Issue:
8
Journal Article
Peer reviewed
Open access
In 2009, the Center for Medicare & Medicaid Services (CMS) began public reporting on risk-standardized hospital readmission rates for specific conditions that affect significant numbers of Medicare ...beneficiaries: acute myocardial infarction, heart failure, and pneumonia. ...national health care reimbursement policy makers, including CMS and large payers, need to consider that there may be a limit to the extent to which acute-care readmission or post-discharge or hospital-based care rates can be decreased. ...there is likely a tipping point beyond which the negative consequences of public reporting and financial penalties for higher-than-average readmission rates will outweigh the societal benefits, which at this time are principally measured in dollars saved to payers.
An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for ...an individual patient. ...clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of "no benefit" or is associated with "harm" to the patient.\n Jude Medical The Medicines Company* None None James Bernard Hermiller Content Reviewer--ACCF Interventional Scientific Council Abbott Boston Scientific St. Jude Medical Eli Lilly None None None None Fred M. Kosumoto Content Reviewer None None None None None None Glenn Levine Content Reviewer None None None None None None Roxana Mehran Content Reviewer Abbott Vascular AstraZeneca Ortho-McNeill None None BMS/Sanofi-aventis* The Medicines Company* None None M. Eugene Sherman Content Reviewer--ACCF Board of Governors None Eli Lilly* None None None None Daniel I. Simon Content Reviewer Cordis/Johnson & Johnson Daiichi-Sankyo Eli Lilly Medtronic Sanofi-aventis The Medicines Company None None None None Defendant, DES Intellectual Property Case, 2010 Richard W. Smalling Content Reviewer--ACCF Interventional Scientific Council AGA Medical None None AGA Medical* Cordis* eValve* AGA Medical Cordis eValve None William G. Stevenson Content Reviewer-- ACCF/AHA Task Force on Practice Guidelines None None None None None None William A. Tansey III Content Reviewer None None None None None None David D. Waters Content Reviewer Bristol-Myers Squibb Pfizer None None None Merck/Schering-Plough Sanofi-aventis (DSMB) None Christopher J. White Content Reviewer None None None Boston Scientificdagger St. Jude Medical None None Clyde W. Yancy Content Reviewer-- ACCF/AHA Task Force on Practice Guidelines None None None None None None Yerem Yeghiazarians Content Reviewer None None None None None None * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. Names are listed in alphabetical order within each category of review.According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person's household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document.ACCF indicates American College of Cardiology Foundation; ACEP, American College of Emergency Physicians; AHA, American Heart Association; DES, drug-eluting stent; DSMB, data safety monitoring board; and SCAI, Society for Cardiovascular Angiography and Interventions.
Background Thrombotic and bleeding complications are major concerns during orthopedic surgery. Given the frequency of orthopedic surgical procedures and the limited data in the literature, we sought ...to investigate the incidence and risk factors for thrombotic (myocardial necrosis and infarction) and bleeding events in patients undergoing orthopedic surgery. Methods and Results We performed a retrospective cohort analysis of 3,082 consecutive subjects ≥21 years of age undergoing hip, knee, or spine surgery between November 1, 2008, and December 31, 2009. Patient characteristics were ascertained using International Classification of Diseases, Ninth Revision , diagnosis coding and retrospective review of medical records, and laboratory/blood bank databases. In-hospital outcomes included myocardial necrosis (elevated troponin), major bleeding, coded myocardial infarction, and coded hemorrhage as defined by International Classification of Diseases, Ninth Revision , coding. Of the 3,082 subjects, mean age was 60.8 ± 13.3 years, and 59% were female. Myocardial necrosis, coded myocardial infarction, major bleeding, and coded hemorrhage occurred in 179 (5.8%), 20 (0.7%), 165 (5.4%), and 26 (0.8%) subjects, respectively. Increasing age ( P < .001), coronary artery disease ( P < .001), cancer ( P = .004), and chronic kidney disease ( P = .01) were independent predictors of myocardial necrosis, whereas procedure type ( P < .001), cancer ( P < .001), female sex ( P < .001), coronary artery disease ( P < .001), and chronic obstructive pulmonary disease ( P = .01) were independent predictors of major bleeding. Conclusion There is a delicate balance between thrombotic and bleeding events in the perioperative period after orthopedic surgery. Perioperative risk of both thrombosis and bleeding deserves careful attention in preoperative evaluation, and future prospective studies aimed at attenuating this risk are warranted.
Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions.
To assess the predictive value of classification ...schemes that estimate stroke risk in patients with AF.
Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge.
Hospitalization for ischemic stroke, determined by Medicare claims data.
During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval CI, 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6.
The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.
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