Symptomatic In-Hospital Deep Vein Thrombosis and Pulmonary Embolism Following Hip and Knee Arthroplasty Among Patients Receiving Recommended Prophylaxis A Systematic Review

ArticleinJAMA The Journal of the American Medical Association 307(3):294-303 · January 2012with35 Reads
DOI: 10.1001/jama.2011.2029 · Source: PubMed
Abstract
Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined. To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA. Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles. Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa. Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.
    • "Measures of ICU and hospital mortality have similarly been proposed [10,76]. Systematic reviews and meta-analyses have been used to derive quality improvement benchmarks [77], and our present study provides literature-based estimates of readmission to the ICU and hospital mortality that could be used by institutions to select potential benchmark values. So, which literature-based estimates should be considered? "
    [Show abstract] [Hide abstract] ABSTRACT: IntroductionTo derive literature-based summary estimates of readmission to ICU and hospital mortality for patients discharged alive from ICU.Methods We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials from inception to March 2013, as well as reference lists of included studies. We selected cohort studies of ICU discharge prognostic factors that reported readmission to ICU or hospital mortality among patients discharged alive from ICU. Two reviewers independently abstracted the number of patients readmitted to ICU and hospital deaths among patients discharged alive from ICU. Fixed effect and random effects models were used to estimate the pooled cumulative incidence of ICU readmission and the pooled cumulative incidence of hospital mortality.ResultsThe analysis included 58 studies (n¿=¿2,075,610 patients). The majority of studies followed patients until hospital discharge (n¿=¿46) and reported readmission to ICU (n¿=¿44) or hospital mortality (n¿=¿45). The cumulative incidence of ICU readmission was 4.0 readmissions (95% confidence interval (CI), 4.0 to 4.1) per 100 patient discharges using fixed effect pooling and 6.3 readmissions (95% CI, 5.5 to 7.2) per 100 patient discharges using random effects pooling. The cumulative incidence of hospital mortality was 3.3 deaths (95% CI, 3.3 to 3.4) per 100 patient discharges using fixed effect pooling, and 7.4 deaths (95% CI, 6.6 to 8.2) per 100 patient discharges using random effects pooling. There was significant heterogeneity for the pooled estimates that was partially explained by patient, institution and study methodology characteristics.Conclusions Using current literature estimates, for every 100 patients discharged alive from ICU, on average between 4 and 6 patients will be readmitted to ICU and between 3 and 7 patients will die prior to hospital discharge. These estimates can inform the selection of benchmarks for quality metrics of transitions of patient care between the ICU and hospital ward.
    Full-text · Article · Dec 2014
    • "The rates of events in the absence of prophylaxis, required for estimation of benefits and risks, can come only from systematic reviews of the relevant studies. Nevertheless, few such systematic reviews have been undertaken in any area of surgery [8] and none in urology [3]. One reason for the dearth of such reviews is the multiple challenges they present. "
    [Show abstract] [Hide abstract] ABSTRACT: Pharmacological thromboprophylaxis in the peri-operative period involves a trade-off between reduction in venous thromboembolism (VTE) and an increase in bleeding. Baseline risks, in the absence of prophylaxis, for VTE and bleeding are known to vary widely between urological procedures, but their magnitude is highly uncertain. Systematic reviews and meta-analyses addressing baseline risks are uncommon, needed, and require methodological innovation. In this article, we describe the rationale and methods for a series of systematic reviews of the risks of symptomatic VTE and bleeding requiring reoperation in urological surgery.Methods/design: We searched MEDLINE from January 1, 2000 until April 10, 2014 for observational studies reporting on symptomatic VTE or bleeding after urological procedures. Additional studies known to experts and studies cited in relevant review articles were added. Teams of two reviewers, independently assessed articles for eligibility, evaluated risk of bias, and abstracted data. We derived best estimates of risk from the median estimates among studies rated at the lowest risk of bias. The primary endpoints were 30-day post-operative risk estimates of symptomatic VTE and bleeding requiring reoperation, stratified by procedure and patient risk factors. This series of systematic reviews will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding. Our work advances standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at best estimates of risk (including modeling of timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate certainty in estimates of risk. The results will be incorporated in the upcoming European Association Urology Guideline on Thromboprophylaxis.Systematic review registration: PROSPERO CRD42014010342.
    Full-text · Article · Dec 2014
    • "On average, the rate of symptomatic VTE 90 days after such surgery is about 3.6% and the rate of fatal PE is 0.13%567 . A recent metaanalysis suggests that the rates of symptomatic VTE prior to discharge from the hospital in patients undergoing hip or knee arthroplasty are 0.5% and 1.1%, respectively [8]. However, results from a global registry indicate that the median length of stay for these patients has been reduced to 3 to 4 days, respectively [9]. "
    [Show abstract] [Hide abstract] ABSTRACT: New, non-vitamin K antagonist oral anticoagulants (NOACs) have been developed to overcome the limitations of warfarin. These include dabigatran, which inhibits thrombin, and rivaroxaban, apixaban, and edoxaban, which inhibit factor Xa. In the US, rivaroxaban and apixaban are licensed for thromboprophylaxis after elective hip or knee arthroplasty, and rivaroxaban and dabigatran are approved for treatment of venous thromboembolism. Dabigatran, rivaroxaban, and apixaban also are licensed for stroke prevention in eligible patients with atrial fibrillation. Designed to be given in fixed doses without routine coagulation monitoring, the NOACs are more convenient to administer than warfarin. Phase III clinical trials have shown that the NOACs are at least as effective as warfarin and are associated with less intracranial bleeding. This article compares the pharmacological properties of the NOACs with those of warfarin, describes the clinical trial data with the NOACs in the approved indications, outlines the unmet medical needs that the NOACs address, highlights the potential limitations of the NOACs, and provides guidance on the optimal use of the NOACs.
    Full-text · Article · Oct 2014
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