Publications by Year: 2018

BACKGROUND: Venous thromboembolism (VTE) is the third leading cause of vascular disease and accounts for $10 billion in annual US healthcare costs. The nationwide burden of 30-day readmissions after such events has not been comprehensively assessed.

METHODS AND RESULTS: We analyzed adults ≥18 years of age with hospitalizations associated with acute VTE between January 1, 2010, and December 31, 2014, in the Nationwide Readmissions Database. International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify hospitalizations associated with acute pulmonary embolism or deep vein thrombosis. The primary outcome was the rate of unplanned 30-day readmission. Hierarchical logistic regression was used to calculate hospital-specific 30-day risk-standardized readmission rates, a marker of healthcare quality. Among 1 176 335 hospitalizations with acute VTE, in-hospital death occurred in 6.2%. VTE was associated with malignancy in 19.7%, recent surgery in 19.3%, recent trauma in 4.6%, hypercoagulability in 3.3%, and pregnancy in 1.0%. Among survivors to discharge, the 30-day readmission rate was 17.5%, with no significant difference in rates across study years (17.4%-17.7%; P=0.10 for trend). Major predictors of readmission were malignancy (relative risk, 1.49, 95% confidence interval 1.47-1.50), Medicaid insurance (relative risk, 1.48, 95% confidence interval 1.46-1.50), and nonelective index admission (relative risk, 1.31, 95% confidence interval 1.29-1.33). Top causes of readmission included sepsis (9.6%) and procedural complications (8.1%). Median rehospitalization costs were $9781.7 (interquartile range, $5430.7-$18 784.1), and 8.1% died during readmission. The interquartile range in risk-standardized readmission rates was 16.6% to 18.3%, suggesting modest interhospital heterogeneity in readmission risk.

CONCLUSIONS: Nearly 1 in 5 patients with acute VTE were readmitted within 30 days. Predictors and causes of readmission were primarily related to patient characteristics and complications from comorbid conditions, whereas healthcare quality had a moderate impact on readmission risk.

Web-based surveys, or e-surveys, are surveys designed and delivered using the internet. The use of these survey tools is becoming increasingly common in medical research. Their advantages are appealing to surveyors because they allow for rapid development and administration of surveys, fast data collection and analysis, low cost, and fewer errors due to manual data entry than telephone or mailed questionnaires. Internet surveys may be used in clinical and academic research settings with improved speed and efficacy of data collection compared with paper or verbal survey modalities. However, limitations such as potentially low response rates, demographic biases, and variations in computer literacy and internet access remain areas of concern. We aim to briefly describe some of the currently available Web-based survey tools, focusing on advantages and limitations to help guide their use and application in dermatologic research.

Background: Over-the-counter (OTC) lightening agents are commonly used to treat hyperpigmentation disorders. Objective: We sought to determine the characteristics, trends, and preferences of patients with hyperpigmentation disorders seeking OTC agents in the United States. Design: The study was a cross-sectional study of consecutive patients with a disorder of hyperpigmentation seen in a United States-based outpatient dermatology clinic. Multivariable logistic regression models were used to identify factors associated with the use of OTC lightening agents. Setting: The study setting was an outpatient US-based dermatology clinic in Boston, Massachusetts. Results: Of the 406 patients studied, the majority were women (88.9%) with Fitzpatrick Skin Types IV to VI (64.5%). The most frequent diagnoses were melasma (42.9%) and post-inflammatory hyperpigmentation (PIH, 33.9%). Of our responders, 51.0 percent reported use of OTC agents and 44.9 percent reported use of prescription lightening products. Hydroquinone was the most commonly used cream (59.1%), followed by triple combination cream (fluocinolone acetonide, hydroquinone, and tretinoin, 16.3%). Of the cohort, 28.9 percent felt that the greater expense of the product correlated with greater efficacy. After multivariable adjustment, factors associated with a greater odds of using an OTC lightening agent included having a diagnosis of melasma (odds ratio [OR] 5.36; 95% CI: 2.98, 9.63; P<0.01) or PIH (OR 2.38; 95% CI: 1.25, 4.53; P≤0.01). Conclusion: The use of OTC lightening agents is widespread among those patients with hyperpigmentation disorders who reside in the United States. Those with melasma and PIH were more likely to use an OTC lightening cream. The majority of patients believed that OTC creams were safe to use without physician supervision. In those who had also tried prescription products, triple combination was deemed most effective compared to other lightening agents.

PURPOSE OF REVIEW: More than 9% of patients who undergo percutaneous coronary intervention (PCI) carry a concomitant indication for long-term anticoagulation (OAC). The optimal combination of anticoagulation and antiplatelet therapy for these patients remains uncertain.

RECENT FINDINGS: Numerous studies have demonstrated that dual antiplatelet therapy (DAPT) remains superior to vitamin K antagonists (VKA) in the prevention of stent-related events. Nonetheless, OAC therapy is more efficacious than DAPT at reducing thromboembolism in patients with atrial fibrillation. The combination of DAPT and OAC, known as triple therapy, portends as much as a threefold increased risk of fatal and nonfatal bleeding compared to warfarin monotherapy. Recent studies have demonstrated the safety of shorter durations of triple therapy with subsequent transition to a P2Y12 inhibitor in combination with an OAC. Here, we review the evidence regarding the safety and efficacy of dual therapy with OAC in combination with a P2Y12 inhibitor versus triple therapy among recently stented patients with a long-term requirement for OAC.

BACKGROUND: Limited data suggest high rates of unplanned rehospitalization after endovascular and surgical revascularization for peripheral arterial disease. However, the overall burden of readmissions has not been comprehensively explored.

OBJECTIVE: To evaluate nationwide readmissions after peripheral arterial revascularization for peripheral arterial disease and to assess whether readmission risk varies among hospitals.

DESIGN: Retrospective cohort study.

SETTING: 1085 U.S. acute care hospitals participating in the Nationwide Readmissions Database.

PATIENTS: 61 969 unweighted hospitalizations of patients with peripheral arterial disease who had peripheral arterial revascularization and were discharged alive between 1 January and 30 November 2014.

MEASUREMENTS: 30-day readmission rates, causes, and costs of unplanned rehospitalizations after peripheral arterial revascularization; 30-day risk-standardized readmission rates (RSRRs), calculated using hierarchical logistic regression, to assess for heterogeneity of readmission risk between hospitals.

RESULTS: Among 61 969 hospitalizations of patients with peripheral arterial disease who were discharged alive after peripheral arterial revascularization, the 30-day nonelective readmission rate was 17.6%. The most common cause of readmission was procedural complications (28.0%), followed by sepsis (8.3%) and complications due to diabetes mellitus (7.5%). Among rehospitalized patients, 21.0% underwent a subsequent peripheral arterial revascularization or lower extremity amputation, 4.6% died, and the median cost of a readmission was $11 013. Thirty-day RSRRs varied from 10.0% to 27.3% (interquartile range, 16.6% to 18.8%).

LIMITATION: Inability to distinguish out-of-hospital deaths after discharge and potential misclassification bias due to use of billing codes to ascertain diagnoses and interventions.

CONCLUSION: More than 1 in 6 patients with peripheral arterial disease who undergo peripheral arterial revascularization have unplanned readmission within 30 days, with high associated mortality risks and costs. Procedure- and patient-related factors were the primary reasons for readmission. Readmission rates varied moderately between institutions after hospital case mix was accounted for, suggesting that differences in hospital quality may only partially account for readmission.

PRIMARY FUNDING SOURCE: Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center.

Determining the optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention is a complex decision. Randomized controlled trials have shown that while shorter durations of DAPT may lower the risk of bleeding, longer durations of DAPT can reduce the risk of late stent thrombosis and ischemia-related events. In this review article, we will discuss the current guidelines, review contemporary trial data that have evaluated short and extended durations of DAPT, and address common clinical questions. Ultimately, the determination of the optimal duration of DAPT is an individualized decision that requires clinicians to assess each patient's risk for bleeding and recurrent ischemic events.