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Management of acute venous thromboembolism among a cohort of patients discharged directly from the emergency department
  1. Tammy J Bungard1,
  2. Bruce Ritchie2,
  3. Jennifer Bolt3,
  4. William M Semchuk3
  1. 1 Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
  2. 2 Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
  3. 3 Pharmacy Services, Regina Qu’Appelle Health Region, Regina, Saskatchewan, Canada
  1. Correspondence to Dr Tammy J Bungard; tammy.bungard{at}ualberta.ca

Abstract

Objective To report the proportion of patients discharged directly from the emergency department (ED) on traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC) for the management of acute venous thromboembolism (VTE).

Design Retrospective medical record review across four EDs in Edmonton, Alberta, two in Regina, Saskatchewan and three in rural Alberta.

Setting EDs from April 2014 through March 2015.

Participants Discharged directly from the ED with acute VTE. Patients were excluded if they had another indication for anticoagulants, were pregnant/breastfeeding or anticipated lifespan <3 months.

Primary and secondary outcome measures Primarily, the proportion of patients discharged directly from the ED that were prescribed traditional therapy or a DOAC, with comparisons between Edmonton, Regina and rural Alberta. Secondarily, therapy selection was compared based on deep vein thrombosis (DVT) versus pulmonary embolism (PE) and clot burden. Dosing of DOACs was assessed (when applicable) and follow-up in the community was compared.

Results After screening 1723 patients, 417 (24.2%) were included with DVT and PE occurring in 65.5% and 34.5%, respectively. More patients with PE were discharged from EDs in Edmonton (43%) than Regina (7%). Overall, the majority of patients were discharged on traditional therapy (70.7%), with 27.8% receiving a DOAC. Uptake of DOAC use was highest in rural Alberta (53.3%) compared with Edmonton (29.6%) and Regina (12.1%). DOACs were more commonly prescribed for PE (34.0%) than DVT (24.5%) (p=0.04), proximal versus distal DVT (28.4% and 17.3%; p<0.001), and when prescribed were appropriately dosed in 79.3%. Follow-up most commonly occurred via a VTE clinic in Edmonton or family physician in Regina and rural Alberta.

Conclusions Regional variation in discharging patients directly from the ED with PE is evident. While traditional therapy is most common, uptake of DOACs was modest given the timing of indication approval.

  • audit
  • anticoagulation
  • clinical audit

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • Contributors TJB drafted the initial protocol, participated in data acquisition, analysis and interpretation. She also drafted the initial manuscript and approved the final version to be published. BR critically reviewed the research protocol, contributed to the data interpretation, critically revised the manuscript and approved the final version to be published. JB participated in data acquisition, data analysis and interpretation, critically reviewed the manuscript and approved the final version. WS critically reviewed the research protocol, participated in data analysis and interpretation, critically reviewed the manuscript and approved the final version to be published. All authors are accountable for all aspects of the work.

  • Funding Funding was received from Pfizer Canada (via Dr. Bungard) in the form of an unrestricted grant.

  • Disclaimer The sponsor had no role in the protocol design, study conduct, analysis/interpretation of the findings or decision to publish.

  • Competing interests TJB has received honoraria for an advisory board from Boehringer Ingelheim, as well as honoraria for speaking from Bayer. TJB has received unrestricted grants from Pfizer and Leo Pharma Canada. BR has served on advisory boards, given sponsored lectures using his own slides and received travel expense remuneration for Bayer, Baxter, Beohringer-Ingelheim, CSL-Behring, Pfizer, Sanofi, Servier and Shire. In lieu of honoraria for these activities, the companies have given financial contributions to the University of Alberta. BR reports grants from Novo Nordisk, CSL-Behring and Baxter, all outside of this submitted work. JB has received speaker honoraria from Boehringer Ingleheim in the past two years. WS has received honoraria from Bayer, Pfizer, Bristol Myers Squibb and Boehringer Ingleheim. He has served as a consultant or on an Advisory Board for Bayer and Pfizer/Bristol Myers Squibb and he has received an unrestricted research grant from Pfizer.

  • Patient consent Not required.

  • Ethics approval Health Research Ethics Board-Health, University of Alberta (Pro00056384); Regina Qu’Appelle Health Region Ethics Board (REB 15-65).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There is no data sharing agreement in place.

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