Search

People with type 2 diabetes mellitus (T2DM) and diabetic kidney disease (DKD) have increased morbidity and mortality risk. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) are recommended to slow kidney function decline in DKD. This representative, real-world data analysis of patients with T2DM was performed to detect onset of DKD and determine methods and timing of DKD diagnosis and time to initiation of ACEi/ARB therapy. Patients diagnosed with T2DM before January 1, 2016 who developed DKD between January 1, 2017 and June 30, 2019 were identified from a longitudinal ambulatory electronic health record (EHR) dataset (Veradigm Inc). Each record was analyzed using the CLinical INTelligence engine (CLINT™, HealthPals, Inc.) to identify delays and gaps in diagnosing DKD. DKD was diagnosed through two reduced estimated glomerular filtration rate (eGFR; 30 mg/g) measurement, or ICD-9/10 diagnosis codes for DKD and/or albuminuria. Time to diagnose (TTD), time to treat (TTT), and diagnosis to treatment time were assessed. Of 6,499,409 patients with T2DM before January 2016, 245,978 developed DKD between January 1, 2017 and June 30, 2019. In this DKD cohort, ca. 50% were first identified through EHR diagnosis and ca. 50% by UACR or eGFR lab-based diagnosis. In patients who had UACR/eGFR assessed, more than 90% exhibited DKD-level results on the first diagnostic test. Average TTD after eGFR labs was 2 years; average TTT with ACEi/ARB was 6–9 months after DKD lab evidence. The majority of patients who developed DKD received ACEi/ARB therapy 6–7 months after diagnosis. In a contemporary, large national cohort of patients with T2DM, progression to DKD was common but likely underrepresented. The low rate of DKD-screening labs, along with sizable delays in diagnosis of DKD and initiation of ACEi/ARB therapy, indicates that many patients who progress to DKD are not being properly treated. Diabetic kidney disease is kidney disease that occurs in patients with type 2 diabetes and is associated with greater risk of death and other adverse cardiovascular and kidney outcomes. Unfortunately, diabetic kidney disease is underdiagnosed because of lack of awareness and its early asymptomatic presentation. Early detection and treatment of diabetic kidney disease with medicines such as angiotensin-converting enzyme inhibitors (also known as ACE inhibitors) or angiotensin II receptor blockers (also known as ARBs) is important for the prevention of disease progression and the development of other serious conditions. This real-world analysis evaluated electronic health record data from more than 6 million patients with diabetes to detect the onset of diabetic kidney disease and to determine timing of treatment and gaps in medical care. Results from the study show that there are often significant delays in the diagnosis of diabetic kidney disease, even when laboratory evidence is available. Furthermore, many patients are not undergoing regular renal function testing, thus missing the opportunity for diagnosis (and subsequent treatment) of earlier onset, less severe disease. After diagnosis, patients with diabetic kidney disease experience significant delay until they receive appropriate treatment with an ACE inhibitor or ARB. The low rate of kidney function screening coupled with delays in diagnosis and treatment initiation suggest that many patients who progress to diabetic kidney disease are not being properly treated. The results from this study highlight the need to improve diagnostic and treatment protocols to address these significant gaps in care.

Introduction Hospitalization is the largest component of health care spending in the United States. Most hospitalized patients first visit the emergency department (ED), where hospitalization decisions are made. Optimal utilization of hospital resources is critical for all stakeholders. Methods We performed a population-based, cross-sectional study evaluating ED visits and subsequent inpatient admissions for patients with coronary artery disease (CAD) and chest pain (CP) suggestive of CAD from 2006 to 2013 using the Nationwide Emergency Department Sample database weighted for national estimates. We analyzed trends using a generalized linear regression model with a Poisson distribution and Wald test. Results From 2006 to 2013, there was a 15% decrease in ED visits for CAD (p

Background Inflammatory bowel disease (IBD) is a chronic disease with the potential for significant morbidity in case of suboptimal treatment (e.g. low treatment adherence). In spite of immense research in IBD, literature on association of IBD with race/ethnicity is fragmented. In this study, we aimed to evaluate the association between race/ethnicity and treatment adherence and persistence among patients with Crohn’s disease (CD) or ulcerative colitis (UC) initiated with biologic therapies. Methods This observational, retrospective study utilized the Optum Clinformatics (Optum) Extended Data Mart Socioeconomic Status (SES) database. Adult patients with ≥ 2 medical claims for CD or UC diagnosis, ≥ 1 medical or pharmacy claim for corresponding FDA-approved biologic therapy, and a ≥ 12-month pre-index (index date: date of the first biologic medical/pharmacy claim) continuous health plan enrollment were included. Treatment adherence was measured as the proportion of days covered of ≥ 80% and treatment persistence by the number of days from the index date to the biologics discontinuation date. Switching among biologics was allowed for both treatment adherence and treatment persistence. Multivariable regression analyses were performed to evaluate the association between race/ethnicity and treatment adherence/persistence. Results Among patients with CD (N = 1430) and UC (N = 1059) included, majority were White (CD: 80.3%, UC: 78.3%), followed by African Americans (AA; CD: 10.5%, UC: 9.7%). Among patients with CD, AA were significantly less likely to adhere to biologics (adjusted OR [95%CI]: 0.61 [0.38; 0.99]) and more likely to discontinue biologics earlier (adjusted HR [95%CI]: 1.52 [1.16; 2.0]) during the follow-up period compared to Whites, after adjusting for other patient sociodemographic and clinical characteristics. Among patients with UC, no significant differences in the treatment adherence/persistence were observed between different races/ethnicities. Conclusions Patients with CD were found to display racial differences in the treatment adherence and persistence of biologics, with significantly lower adherence and earlier discontinuation in AA compared to Whites. Such differences were not observed in patients with UC. Future studies are warranted to understand the possible reasons for racial differences, particularly in patients with CD.

OBJECTIVES Ticket to Home (TTH), a survey tool designed to assess parental comprehension of their child’s hospitalization and postdischarge care needs, allows providers to address knowledge gaps before discharge. Our goal was to evaluate the impact of TTH on parents’ retention of discharge teaching. METHODS In this pilot study, we enrolled a convenience sample of families admitted to pediatric hospital medicine and randomly assigned families on the basis of team assignment. The intervention group received TTH before discharge. The control group received usual care (without TTH survey tool). Both groups were sent a survey 24 to 72 hours postdischarge to assess parental understanding of discharge teaching. A senior-level provider also completed a survey; responses were compared with evaluate parent level of understanding. Descriptive statistics and logistic regression were used for analysis. RESULTS Although 495 parents consented to participate, only 100 completed the necessary surveys (41 intervention and 59 control). Both groups showed high parent-provider concordance regarding reason for admission (92.7% intervention versus 86.4% control; P = .33). The intervention group had significantly higher concordance for return precautions (90.2% vs 58.2%; P < .001), which remained significant when controlling for covariates (odds ratio 6.24, 95% confidence interval 1.78–21.93). Most parents in the intervention group felt sharing TTH responses with their medical team was beneficial (95.0%). CONCLUSIONS Parents who received TTH before discharge were more likely to accurately recall return precautions and valued sharing TTH results with the team. Given that response bias may have affected pilot results, additional studies in which researchers use larger samples with more diverse patient populations is required.

We compared self-reported domains of health between patients who with vs. without a recent heart failure (HF) hospitalization. We fielded a 59-item questionnaire that included the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) to age/sex-matched groups of 2000 HF patients who had and had not had a recent HF hospitalization. We entered questionnaire responses and electronic medical record data into multivariable logistic regression models to identify independent associations with a HF hospitalization. After two mailings, we received 468 completed questionnaires for response rate of 23.4%. Patients with a recent HF hospitalization had significantly lower scores on the KCCQ-12 Quality of Life (52.6 vs. 59.6, p = 0.016) and Social Limitations (48.4 vs. 55.5, p = 0.009) scales as well as the Clinical Summary Scale (50.8 vs. 55.3, p = 0.048) and Total KCCQ-12 score (49.6 vs. 56.8, p = 0.003). In sequential logistic regression models designed to achieve parsimony, Total KCCQ was a strong predictor of being in the recent hospitalization group. When using the KCCQ-12 sub-scales, the Social Limitations scale was a strong predictor of being in the recent hospitalization group. After accounting for comorbidities and other risk factors, a HF hospitalization appears to profoundly limit social activities which can increase the risk of poor outcomes.

Over the past decade, biopharmaceutical companies have been progressively establishing global frameworks across their capabilities. It is well recognized that the Medical Information (MI) department is a key externally facing function that needs to maintain a consistent focus on optimizing its capabilities of addressing product medical inquiries worldwide.In the United States, a consortium named Pharma Collaboration for Transparent Medical Information, phactMI, a collaboration of pharmaceutical company MI departments dedicated to supporting health care professionals in their commitment to provide quality patient care, has provided a forum to benchmark and share best practices across the companies. In May 2017, phactMI conducted a survey inclusive of 25 biopharmaceutical companies to gain insight into the globalization of respective MI departments and relevant trends.We found increased trends in various aspects of globalization across large, mid, and small size companies, and identified key drivers for success. Overall, 16 of the 25 companies had globalized their MI department, 5 had only partially globalized, and the remaining 4 had not globalized.The findings of this survey will further help inform the MI community as to globalization approaches for a successful outcome.

Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.

Introduction: A non-medical switch is a change to a patient’s medication regimen for reasons other than lack of clinical response, side-effects or poor adherence. Specialist physicians treat complex patients who may be vulnerable to non-medical switching. Objectives: To evaluate specialist physicians’ perceptions regarding the frequency of non-medical switch requests, and the impact on their patients’ outcomes and healthcare utilization. Methods: An online survey of randomly sampled physicians spending ≥10% of time providing patient care and having received ≥1 non-medical switch request during the prior 12-months. Results: Among 404 specialist physicians surveyed, non-medical switch requests were reported as very frequent or frequent by 35.0% of oncologists (for injectable cancer agents) and up to 80.3% of endocrinologists (for injectable anti-hyperglycemics). Respondents reported decreased medication effectiveness (25.0% of oncologists to 75.0% of dermatologists) and increased side-effects (32.5% of oncologists to 66.7% of psychiatrists). Most specialists reported very frequent or frequent increases in non-office visits (52.5% of oncologists to 75.3% of endocrinologists) and calls with pharmacies (57.5% of oncologists to 80.5% of rheumatologists) due to non-medical switching. Conclusions: Receipt of non-medical switching requests were common among specialist physicians. Non-medical switching may lead to negative effects on patient care and require increased healthcare utilization.

Background: Non-medical switching refers to a change in a stable patient’s prescribed medication to a clinically distinct, non-generic, alternative for reasons other than poor clinical response, side-effects or non-adherence. Objective: To assess the perceptions of high-volume Medicare and/or Medicaid physician providers regarding the impact non-medical switching has on their patients’ medication-related outcomes and health-care utilization. Methods: We performed an e-survey of high-volume Medicare and/or Medicaid physicians (spending >50% of their time caring for Medicare and/or Medicaid patients), practicing for >2 years but

Background Physicians are in an ideal position to describe the impact of medication non-medical switching (switching commonly due to formulary changes by insurer for reasons unrelated to patient health) on their practice dynamics and patient care. We sought to examine physicians’ openness to requests for non-medical switching and their experiences and opinions regarding the impact of non-medical switching on their practice, staff and patients. Methods An online survey of randomly-sampled physicians spending ≥10% of time providing patient care and having received ≥1 non-medical switch request during the prior 12-months. The impact of non-medical switching on clinical decision-making process; professional experience with clinical practice, patient-physician relationship, insurance process; and perceived impact on practice, staff and patients were assessed. Weighted percent responses were calculated. Results We sampled 1,010 physicians (response rate = 55.5%). Many responded being frequently not amenable (26.0%) or had reservations (41.8%) to non-medical switch requests; with >50% indicating patient stability on current therapy and suboptimal alternatives as factors frequently influencing amenability. Physicians agreed non-medical switching can create ethical concerns (clinical judgement, autonomy, ability to treat per guidelines; 74.8%, 82.3%, 53.5%, respectively), while forcing them to take responsibility for insurers’ decisions (81.1%) and diverting their clinical time (84.3%). Most indicated non-medical switching increased practice burden (administrative, non-billable interactions, additional staffing, non-office patient contact, calls to/from the pharmacy; 85.0%, 72.5%, 62.2%, 64.2%, 69.5%, respectively). Physicians felt insurer processes discouraged non-medical switch challenges (76.7%) and required inconvenient lengths-of-time (76.1%) speaking to insurer representatives without proper expertise (62.0%). They believed non-medical switching negatively impacted aspects of care (effectiveness, side-effects, medication adherence and abandonment, out-of-pocket costs, medication errors; 46.5%, 53.2%, 50.6%, 49.4%, 59.6%, 54.5%, respectively). Conclusions Physicians were frequently not amenable or had reservations regarding non-medical switching. They noted ethical concerns due to non-medical switching. Most felt non-medical switches burdened their practice and negatively impacted care.

Removal of the uterus at the time of delivery or within the puerperium period is known as emergency obstetric hysterectomy. Obstetric hysterectomy is a lifesaving procedure performed in cases of uncontrolled uterine haemorrhage in placenta previa, placenta accrete, or uterine atony. Being one of the important factors in uterine morbidity, maternal age has also a role in emergency obstetric hysterectomy. The present study was performed to identify the relation between maternal age and emergency obstetric hysterectomy. The study was conducted in tertiary care centres and medical colleges of Gujarat from May 2010 to January 2020. Data was collected from 169663 patients who delivered during the study period, 291 patients underwent emergency obstetric hysterectomy were studied for the objectives of the study. 58.07% (169 out of 291) patients in the study were more than 35 years of age. The study found a statistically signicant relationship between the maternal age and incidence rate. Summary: The incidence rate of emergency obstetric hysterectomy increases with the maternal age.

The deployment of oral multi-unit pellet formulation has gained significant attention in recent years conferring to numerous applications, especially in achieving modified release and acid resistance property. The fluidized bed coating, specifically Wurster technique is commercially utilized for pellet manufacturing, which is a complex process involving too many variables. Risk assessment tools can be employed to determine the critical variables affecting the pre-defined quality profile and screen out important parameters out of literally hundreds of variables to develop a robust product. The present review aims to describe possibly all the variables involved in Wurster coating process and application of FMEA in pellet manufacturing. A brief case study regarding applicability of FMEA to study the effects of critical factors is outlined. Risk assessment tools assist to reduce number of trials to manageable levels with aid of prior art, literature, and preliminary trials to develop an optimized product.

Background: Coronary artery disease (CAD) is strongly associated with development of heart failure (HF). Most studies have focused on predictors of HF among patients with acute CAD presentations (e.g., myocardial infarction (MI)). Although there is a significant risk to develop HF among patients with chronic CAD, the risk factors have been less frequently studied in that group. Thus, the goal of this study is to develop a HF risk prediction model for patients with chronic CAD. Methods: We conducted a retrospective study based on data from electronic medical records (EMR) of adults who received healthcare services for a minimum of 2 years during 2003-2018 at a single integrated healthcare system. Patients were eligible if they: i) had newly diagnosed CAD, defined based on diagnosis and/or procedures codes for CAD, MI, angina, coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention (PCI), and ii) had a stable form of disease (either were not admitted to the hospital at diagnosis (i.e., non-acute presentation) or were admitted, but discharged alive and without a HF diagnosis; for the latter, the study follow-up started at the time of their first outpatient visit completed after discharge. Cox regression was used to examine the association of 79 candidate predictors, such as demographics, laboratory tests, and diagnoses at baseline, with HF. “High risk” level included patients at the 10% highest risk to develop HF based on the proposed prediction model. Results: Out of the 24,468 patients who met the definition of chronic CAD, 4,443 patients (18%) were diagnosed with HF over a mean follow-up of 5.4 years. The Kaplan Meier-based HF rates were 4%, 6%, and 16% at 6 months, 1 year, and 5 years, respectively. The strongest predictors of HF were older age, lower glomerular filtration rate, atrial fibrillation, edema, and higher blood glucose levels. The c-statistic for the final 12-predictor model (shown in figure) was 0.715. In the “high risk” level, the HF rates were 13%, 18%, and 43% at 6 months, 1 year, and 5 years, respectively. Conclusions: The proposed prediction model identifies patients with chronic CAD at high risk for HF, who would benefit from timely implementation of prevention measures.

Venous thromboembolism (VTE) impacts ∼900,000 individuals annually in the US, causing up to 100,000 deaths. Patients experiencing VTE have heightened risk of recurrence. Initial parenteral anti-coagulation is standard therapy for acute VTE followed by ≥3 months of warfarin, which introduces the risk of major bleeding. Balancing increased risks of bleeding and recurrent VTE remains challenging. Recent clinical trials suggest that rivaroxaban, an oral direct inhibitor of factor Xa, provides an effective, safe, simplified approach to treatment. This study considers the economic implications of these data.This study modeled inpatient, acute, and 1-year VTE costs for a hypothetical commercial plan with 1 million members. At baseline, all VTE patients receive standard therapy. Alternatively, 25% are instead treated with rivaroxaban. Model inputs are trial- and literature-based.Standard therapy for VTE consumes 9474 inpatient days ($31.6 million). Added to that is treatment for 74 recurrences ($1.4 million); major and non-major bleed events ($1 million); and direct costs of anti-coagulation ($5.3 million). Alternatively, a 25% shift to oral anti-coagulation with rivaroxaban reduces inpatient days (by 5%); associated acute-care costs (by 2%); recurrences and costs (by 6%). Four major bleeding events are prevented, at the cost of one additional non-major bleeding event, which, taken together, reduce net utilization by 9%. Direct costs of anti-coagulation increase by 5%.The reduction in inpatient utilization, recurrences, and major bleeding resulting from a 25% shift from standard therapy to rivaroxaban following acute VTE would conserve ∼$860,475 for every 1 million commercial health plan enrollees.

Background: Payment reforms and other policy initiatives are accelerating the shift of risk from payers to providers. As a result, population health management is playing an increasing role in decision making by providers, guided by the Medicare Triple Aim. Reducing avoidable hospitalizations is an important tool for achieving this aim, by increasing quality of care and containing hospital costs. Previous studies have examined the trends over time of emergency department (ED) visits for major diseases. However, there is very little data assessing ED visits related to the symptoms of these major diseases. This study examined the trends of ED visits for chest pain (CP), a symptom suggestive of coronary artery disease (CAD), and of shortness of breath (SOB), a symptom suggestive of congestive heart failure (CHF). Methods: We conducted a population-based cross-sectional study to estimate ED visits for CP suggestive of CAD and for SOB suggestive of CHF in the US for the years 2006 through 2013 at encounter level, using the Nationwide Emergency Department Sample (NEDS) database. We defined CP suggestive of CAD as a principal diagnosis of CP for the ED visit (ICD-9-CM code: 786.5), with a CAD code (410-414) as a secondary diagnosis but no diagnosis for other serious conditions that may trigger CP (e.g., aortic dissection). We defined SOB suggestive of CHF as a principal diagnosis of SOB (ICD-9-CM code: 786.05) for the ED visit with a CHF code (428.0-428.4) as a secondary diagnosis but no diagnosis for other conditions that may trigger SOB (e.g., pneumothorax). Outcome measures included annual number of ED visits and subsequent admissions, weighted for national estimates (2006-2013). We performed a trend analysis in rates over time, which accounted for US census population, for ED visits and subsequent admissions, using a generalized linear regression model with a Poisson distribution and a Wald test. Results: The number of ED visits for CP suggestive of CAD per 100,000 population increased 24.3% from 197 in 2006 to 245 in 2013 (p0.1). Similarly, subsequent admissions for SOB suggestive of CHF were relatively low and stable, from 0.61 admissions per 100,000 in 2006 to 0.72 admissions in 2013 (p>0.1). Conclusions: Our results showed an increasing trend for ED visits and a decreasing trend for subsequent admissions over time for CP suggestive of CAD. However, there appeared no change for ED visits and subsequent admissions over time for SOB suggestive of CHF. Future research is warranted to examine possible reasons for the different ED visit rates for symptoms associated with major diseases such as CAD and CHF.

Objective: Warfarin is widely used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We compared the rates of stroke and major bleeding in NVAF patients with a high stroke risk and low bleeding risk profile during warfarin treated (W+) and warfarin untreated (W−) periods. Method: Insurance claims from six commercial, Medicaid or Medicare databases were analyzed from 2000 to 2014. NVAF patients treated with warfarin, with a CHADS2/CHA2DS2-VASc score ≥2, and an ATRIA score ≤3 at baseline were identified. Incidence rate ratios (IRRs) of stroke and major bleeding were calculated for W + versus W− episodes of person-time, as well as for first 30 days versus beyond 30 days of W + episodes. Results: Among 316,145 patients, anticoagulant prophylaxis with warfarin significantly reduced stroke risk, with IRRs ranging from 0.48 (95% CI: 0.46–0.51) to 0.80 (95% CI: 0.70–0.91), and increased major bleeding risk, with IRRs ranging from 1.13 (95% CI: 1.10–1.15) to 1.95 (95% CI: 1.10–3.45). Stroke and major bleeding rates were higher during the first 30 days of W + than beyond. Conclusion: In NVAF patients at high risk for stroke and low risk for bleeding, our data confirm the effectiveness of anticoagulation for stroke prevention. The decrease in stroke risk of anticoagulation may outweigh the risk of major bleeding events, particularly among elderly patients. Potential risks of warfarin during initiation warrant attention, especially among patients who stop and start therapy repeatedly.

This was a retrospective database analysis (2001-2009) of employees' medical, prescription drug, and absence costs and days from sick leave, short- and long-term disability, and workers' compensation. Employees with an ICD-9 diagnostic code for back or neck pain and an ICD-9 for a back- or neck-related neuropathic condition (eg, myelopathy, compression of the spinal cord, neuritis, radiculitis) or radiculopathy were considered to have nociceptive back or neck pain with a neuropathic component. Employees with an ICD-9 for back pain or neck pain and no ICD-9 for a back- or neck-related neuropathic condition or radiculopathy were defined to have nociceptive back or neck pain. Patients with nociceptive back or neck pain with a neuropathic component were classified as having or not having prior nociceptive pain. Annual costs (medical and prescription drug costs and absence costs) and days from sick leave, short- and long-term disability, and workers' compensation were evaluated. Mean annual total costs were highest ($8512) for nociceptive pain with a neuropathic component with prior nociceptive pain (n=9162 employees), $7126 for nociceptive pain with a neuropathic component with no prior nociceptive pain (n=5172), $5574 for nociceptive pain only (n=35,347), and $3017 for control employees with no back or neck pain diagnosis (n=226,683). Medical, short-term disability, and prescription drugs yielded the highest incremental costs compared to controls. Mean total absence days/year were 8.26, 7.86, 5.70, and 3.44, respectively. The economic burden of back pain or neck pain is increased when associated with a neuropathic component.

The objective of this study was to assess deep vein thrombosis and pulmonary embolism (DVT/PE) recurrence rates and resource utilization among patients with an initial DVT or PE event across multiple payer perspectives. Retrospective analyses were performed using a software tool that analyzes health plan claims to evaluate treatment patterns and resource utilization for various cardiovascular conditions. Six databases were analyzed from three payer perspectives (Commercial, Medicare, and Medicaid). Patients were ≥18 years old with a primary diagnosis of DVT or PE associated with an inpatient and/or emergency room claim, had received an antithrombotic within 7 days before or 14 days after index, and had no diagnosis of atrial fibrillation during follow-up. Outcomes were assessed over a 1 year period following index. More PE patients were hospitalized for their index event than DVT patients (42–59 % DVT and 69–86 % PE) and had longer mean length of stay (2.35–2.95 days DVT and 3.26–3.76 days PE). Recurrent event rates among PE patients (12–32 %) were higher than those for DVT patients (6–16 %) across all payers. The highest rate of recurrence was observed among the Medicaid population [23 % overall (VTE); 16 % DVT; 32 % PE]. All-cause hospitalization in the year following their VTE episode occurred in 23–67 % DVT patients and 30–68 % PE patients. Medicaid had the highest proportion of patients with hospitalizations and ER visits. Recurrent VTE events and all-cause hospitalizations are relatively common, especially for patients who had a PE, and among those in the Medicaid payer population.

Approaches to pain management are diverse, requiring prescribers to evaluate an array of clinical issues and potential solutions. In addition to the difficult task of selecting a treatment option, pain treatment may be further complicated by multiple prescribers, multiple medications, and multiple mechanisms of pain origination.To describe patient demographics (e.g., age, gender); comorbidities; office visits (e.g., physician, chiropractor, physical therapy, psychiatry, allergist); number of different prescribers overall prescription use; pain medications as classified by the World Health Organization's (WHO) pain ladder; adjuvant medications; nonpharmacologic procedures; and potential drug interactions in a broad sample of patients with nociceptive or neuropathic neck or back diagnoses, or osteoarthritis diagnoses, in a commercial population.This claims-data analysis used a cross-sectional cohort comparison with a fixed 2-year observation period from September 1, 2006, to August 31, 2008, for patients in the PharMetrics national managed care database. The assigned cohorts were neuropathic-related neck/back diagnoses (NEURO); neuropathic and nociceptive neck/back diagnoses (NEURO/NOCI); nociceptive neck/back diagnoses without a neuropathic-related diagnosis (NOCI); and only osteoarthritis (OA) diagnoses. All analyses were conducted by cohort. The analysis included the following patient-descriptive variables: patient demographics, comorbidities, office visits, most frequent medical providers and number of different prescribers, all medications, pain medications as classified by the WHO pain ladder, adjuvant medications, adjuvant procedures and potential drug interactions. The goal for selecting these variables was to describe a range of data that might provide insight into the complexity of pain management decisions faced by clinicians.The study included 85,014 patients, classified as NEURO (n = 2,375), NEURO/NOCI (n = 37,019), NOCI (n = 39,496), and OA (n = 6,124). The most frequently occurring comorbidities (observed in40% of patients) included cardiovascular and neuropathic pain conditions. Considering all types of medication claims observed among all cohorts, the overall mean prescription claim count for the 2-year observation period was 57.9 claims (standard deviation 56.2). Weak opioids (WHO pain relief ladder rung 2) accounted for the majority of pain medication claims across all cohorts. Across cohorts, 25.7% of patients had 10 or more days of overlapping drug availability (for inducers or inhibitors of the cytochrome P450 system concomitantly), a measure of potential for drug interactions.Choosing the appropriate pain treatment involves assessing currently used medications for existing illnesses and deciding on the appropriate types of pain medications. However, potentially serious drug-drug interactions are a consequence of multiple drug use, and such a potential requires thoughtful consideration by those involved in patient care.

Introduction Preventing re-hospitalizations among heart failure (HF) has been the focus of a great deal of research but determining which HF patients will experience a new initial hospitalization has been less well-studied. Hypothesis Identifying patients who will be hospitalized for HF within the ensuing year can be determined from data routinely collected in electronic medical records (EMRs). Methods We used the EMRs of Kaiser Permanente Northwest, a 550,000-member integrated delivery system in Portland, OR. Using a case-control design, we identified 1,000 patients with a HF hospitalization in 2016/2017 and no prior hospitalization in the past 12 months and matched them on age and sex to 1,000 patients with an existing HF diagnosis in the same year but who were not hospitalized as of their match's hospitalization (index) date. We collected clinical data from the EMR during the 12 months preceding the index date, including clinical characteristics such as obesity (BMI ≥ 30kg/m 2 ), smoking status, and blood pressure (BP) ≥ 140/90, as well as existing comorbidities including diabetes (DM), coronary artery disease (CAD), atrial fibrillation (AF), and valve disorders for comparison between patients who were and were not hospitalized. Using multivariable logistic regression, we identified characteristics predictive of HF hospitalization and determined the discrimination of the model using the C statistic. Results Patients in both groups were 75±10 years old and 48% were men. All variables included in the multivariable model were highly predictive of HF hospitalization (table). For example, African-American patients more than twice as likely to be hospitalized (OR 2.25, 95% CI 1.28-3.98). Patients with high BP, CAD, DM, AF or valve disorders were 86%, 30%, 65%, 84% and 92% more likely to be hospitalized, respectively. However, the model provided only moderate discrimination (C statistic: 0.66). Conclusions Comorbid conditions can help identify which HF patients will be hospitalized within the next year. Because preventing hospitalization is the most effective way to avoid re-hospitalizations, more robust predictive models are needed. Non-clinical data such as health behaviors, social determinants, and social support may be needed to identify HF patients at greatest hospitalization risk and who are in need of intensive care management. Table. Risk of hospitalization for heart failure.

Background Among long-term care (LTC) residents with atrial fibrillation (AF), the use of warfarin to prevent stroke has been shown to be suboptimal. For those who begin warfarin prophylaxis in LTC, persistence on this therapy has not been reported. Objective This study was conducted to estimate persistence on warfarin among LTC residents with AF. Methods A retrospective analysis was conducted by using data from an LTC database. Pharmacy dispensing data were used to track warfarin use in residents with a diagnosis of AF who were newly started on warfarin therapy. The main outcome measure was persistence of warfarin over the first year of therapy. Survival analysis included Kaplan-Meier plots and a multivariate Cox proportional hazards model to test the association of resident characteristics and conditions with warfarin discontinuation. Results A total of 148 residents new to warfarin therapy met all study inclusion criteria. Median age was 84 years; 69% were female. Median time to therapy discontinuation was 197 days (95% CI, 137–249) across all study residents. By 90 days after the initiation of therapy, 37% (95% CI, 28–47) of study residents had discontinued warfarin; by 1 year, 65% (54%–76%) had discontinued warfarin therapy. The multivariate Cox regression analysis found that the following factors were independently associated with discontinuation of warfarin therapy: age 65 to 74 years (hazard ratio [HR] = 3.01 [95% CI, 1.04–8.73]), female sex (HR = 0.45 [95% CI, 0.24–0.87]), Hispanic race/ethnicity (HR = 2.86 [95% CI, 1.30–6.26]), Midwest region (HR = 2.13 [95% CI, 1.02–4.48]), and Alzheimer disease or dementia (HR = 1.97 [95% CI, 1.05–3.68]). Conclusions Although clinical practice guidelines exist for the prevention of stroke in AF patients, persistence on warfarin therapy seems suboptimal in many LTC residents with AF.

Objective: To evaluate differences among physician specialties in the management of acute pain including prescribing practices and management of opioid-related side effects. Design and participants: The Physicians Partnering Against Pain (P 3 ) survey was a nationwide study of US physicians and their patients with severe to moderate acute pain (

Objectives The aims of the study were to evaluate usage rates of warfarin in stroke prophylaxis and the association with assessed stages of stroke and bleeding risk in long-term care (LTC) residents with atrial fibrillation (AFib). Methods A cross-sectional analysis of two LTC databases (the National Nursing Home Survey [NNHS] 2004 and an integrated LTC database: AnalytiCare) was conducted. The study involved LTC facilities across the USA (NNHS) and within 19 states (AnalytiCare). It included LTC residents diagnosed with AFib (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnostic code 427.3X). Consensus guideline algorithms were used to classify residents by stroke risk categories: low (none or 1+ weak stroke risk factors), moderate (1 moderate), high (2+ moderate or 1+ high). Residents were also classified by number of risk factors for bleeding (0–1, 2, 3, 4+). Current use of warfarin was assessed. A logistic regression model predicted odds of warfarin use associated with the stroke and bleeding risk categories. Results The NNHS and AnalytiCare databases had 1,454 and 3,757 residents with AFib, respectively. In all, 34 % and 45 % of residents with AFib in each respective database were receiving warfarin. Only 36 % and 45 % of high-stroke-risk residents were receiving warfarin, respectively. In the logistic regression model for the NNHS data, when compared with those residents having none or 1+ weak stroke risk and 0–1 bleeding risk factors, the odds of receiving warfarin increased with stroke risk (odds ratio [OR] = 1.93, p = 0.118 [1 moderate risk factor]; OR = 3.19, p = 0.005 [2+ moderate risk factors]; and OR = 8.18, p ≤ 0.001 [1+ high risk factors]) and decreased with bleeding risk (OR = 0.83, p = 0.366 [2 risk factors]; OR = 0.47, p ≤ 0.001 [3 risk factors]; OR = 0.17, p ≤ 0.001 [4+ risk factors]). A similar directional but more constrained trend was noted for the AnalytiCare data: only 3 and 4+ bleeding risk factors were significant. Conclusions The results from two LTC databases suggest that residents with AFib have a high risk of stroke. Warfarin use increased with greater stroke risk and declined with greater bleeding risk; however, only half of those classified as appropriate warfarin candidates were receiving guideline-recommended anticoagulant prophylaxis.

The purpose of this study is to report on the effect of using CHASix administrative claims databases that included medical and pharmacy claims for patients aged ≥18 years with a new or existing diagnosis of AF and patient outcomes assessed for 1 year after diagnosis were analyzed. Retrospective health plan data analyses were performed using a software tool (Anticoagulant Quality Improvement Analyzer). Study measures included stroke risk (identified by CHADSA total of 115,906 patients with AF (range of mean ages among the 6 databases, 56-79 years) met the inclusion criteria. All ranges reported represent the minimum and maximum values among the 6 databases. Using the CHAUse of the CHA

The rate of potential warfarin drug-drug interactions among long-term care (LTC) residents with atrial fibrillation (AFib) is evaluated.LTC residents from two databases, the National Nursing Home Survey (NNHS) 2004 and the AnalytiCare™ multistate database, with an AFib diagnosis (ICD9 = 427.3x) were studied. Concurrent usage was tabulated for 10 agents/pharmacotherapeutic classes (simple-class screen) and for 96 individual agents (single-agent screen) with strong evidence for warfarin-interaction.Warfarin use was recorded in 502 NNHS and 1,674 AnalytiCare residents with AFib. Using the simple-class screen, ≥ 1 of the 10 classes/agents were prescribed concurrently in 59% (CI: 54.0 - 63.6%) of warfarin users in NNHS and 85% (CI: 82.9 - 86.3%) in AnalytiCare. Using the more comprehensive single-agent screen, usage of any interacting agent was higher in both databases: 87% (CI: 83.9 - 90.3%) in NNHS and 94% (CI: 93.0 - 95.3%) in AnalytiCare. Among 873 interacting agents dispensed to residents while continuously using warfarin (AnalytiCare database), 360 (41%) were changed (added or withdrawn), while 513 (59%) were maintained over two consecutive 45-day periods.Concurrent use of agents with a high potential for interaction occurs among most LTC residents who are receiving warfarin. Large proportions of interacting agents appear to be added or withdrawn during continuous warfarin therapy and thus have implications for anticoagulation control.

Our objective was to perform a meta-analysis of randomized controlled trials of dopamine agonists (DA) as monotherapy as well as adjunctive therapy for the early treatment of Parkinson's disease (PD). A systematic literature search was conducted through April 2007. Both efficacy and safety endpoints were evaluated. DA monotherapy showed superior efficacy but more frequent adverse events compared to placebo. In addition, DA demonstrated inferior efficacy to levodopa, but was associated with fewer motor complications. However, DAs were associated with a greater incidence of nuisance side effects, such as hallucinations, somnolence and dizziness. The use of DA is an effective treatment option for the treatment of early PD and appears especially useful among PD patients with wearing-off phenomenon or dyskinesias on levodopa; however it may result in more adverse events and higher withdrawal rates.

Background: To perform a meta analysis of randomised placebo-controlled trials evaluating the use of dopamine agonist (DA) or placebo to preexisting levodopa therapy for the treatment of advanced Parkinson's disease (PD). We focused on clinically important efficacy [Unified Parkinson's Disease Rating Scale (UPDRS) activities of daily living (ADL) and motor scores as well as change in 'off' time and levodopa dose] and safety outcomes (withdrawal because of adverse drug events (ADEs), dyskinesias, hallucinations and mortality). Methods: A systematic literature search was performed between January 1990 and July 2007. The primary outcome measures assessed were the reduction in scores of Unified Parkinson's Disease Rating Scale (UPDRS) activities of daily living (ADL) and motor scores as well as reduction in 'off' time and reductions in levodopa dose from baseline. Safety end-points were also evaluated. Results: A total of 15 trials (n = 4380 subjects) were included in the meta analysis. Adjunctive DA use resulted in greater improvement as measured by the UPDRS ADL [weighted mean difference (WMD) -2.20, 95% confidence interval (Cl) -2.64 to -1.76; p < 0.0001] and motor score reduction (WMD -5.56, 95% Cl -6.82 to -4.31; p < 0.0001) as well as reduction in 'off' time measured in hours/day (WMD -1.20, 95% Cl -1.78 to -0.62; p < 0.0001) and reduction in levodopa dose (WMD -128.5 mg, 95% Cl -175.0 to -82.1; p < 0.0001) vs. placebo. Incidence of dyskinesia and hallucinations was higher with DAs [odds ratio (OR) 3.27, 95% Cl 2.65-4.03; p < 0.0001] and (OR 3.34, 95% Cl 2.44-4.58; p < 0.0001). Non-ergot DAs were qualitatively better, although both ergot and non-ergot DAs showed statistically significant improvements in all UPDRS scores. Conclusion: Adjunctive DA use to levodopa is superior to levodopa alone in reducing PD symptoms in patients not controlled with monotherapy. DAs seem especially useful amongst PD patients with wearing-off phenomenon from levodopa therapy, but can cause some adverse events.

Purpose. The effects of Echinacea purpurea on electrocardiographic and blood pressure measurements in healthy volunteers were evaluated. Methods. Healthy volunteers were randomized to receive a single 350-mg dose of E. purpurea or placebo in a crossover fashion with a seven-day washout period between treatment phases. Twelve-lead electrocardiograms were acquired, and systolic and diastolic blood pressure measurements were taken immediately before (baseline) and at one, three, five, and eight hours after ingestion of the study drug. Electrocardiographic variables (P wave and QRS complex duration and PR, Q-T, Q-Tc, and RR intervals) were measured in lead II by one blinded study investigator. Duplicate blood pressure determinations were taken manually at each time point and then averaged. The maximum posttreatment values, irrespective of time point, for each electrocardiographic and blood pressure measurement were compared between groups. Results. Of the 17 healthy adults initially screened for this study, 16 completed both phases. There was no difference in maximum posttreatment electrocardiographic or blood pressure (systolic or diastolic) variables noted between groups. Mild headache was reported by one patient receiving echinacea and one receiving placebo. One participant receiving echinacea experienced shortness of breath five hours posttreatment and mild flu-like symptoms after eight hours; symptoms completely resolved over the next several days. Conclusion. A single 350-mg dose of E. purpurea had no effect on electrocardiographic and blood pressure measurements of healthy volunteers.

Evaluate the effect of administering intravenous protamine immediately post-radiofrequency catheter ablation (RFCA) on thrombotic and bleeding complications in heparinized patients.Heparinized patients that had RFCA for atrial or ventricular arrhythmias at our institution between January 2001 and March 2006 and had a complete data set were included in this cohort evaluation. Patients receiving at least one dose of protamine within 15 min of RFCA were deemed the prophylactic group while those not receiving protamine within 15 min were the control group. Thrombotic (cerebrovascular event, transient ischemic attack, pulmonary embolism, deep vein thrombosis, or myocardial infarction) and bleeding events (blood loss requiring transfusion, hematoma requiring intervention, or intracranial hemorrhage) were compared between groups.Overall, 158 patients (74% male, 55 +/- 13.5) met inclusion criteria. Of these, 73.4% received prophylactic protamine (average dose = 39 mg +/- 17). Only one patient (0.9%) in the prophylactic protamine group and zero patients in the control group experienced a thrombotic event (p0.99). Only two patients (1.7%) in the protamine group (n = 2 blood transfusions) and zero patients in the control group experienced bleeding events (p = 0.839).Administering prophylactic intravenous protamine to allow for quicker catheter removal following RFCA in heparinized patients did not markedly impact thrombotic or bleeding complication rates in our population. The perceived benefit in our institution to protamine administration in this population is a reduction in postoperative patient immobilization and discomfort, reduced PACU nursing care, and earlier time to discharge. Given the low rate of thrombotic and bleeding events, a study of several thousand patients would be needed to fully evaluate the impact on these events.

Aims: To analyze administrative claims data from Medicaid, Medicare and commercial insurance sources to estimate stroke risk, bleeding risk, and the use of antithrombotic treatment in patients with atrial fibrillation (AF). Methods: Included patients were aged ≥18 years with a new or existing diagnosis of AF. Outcomes were assessed over 1 year and included stroke risk (CHADS 2 /CHA 2 DS 2 -VASc score), bleeding risk (ATRIA score) and anticoagulant use. Results : A total of 115,906 patients with AF met inclusion criteria between six databases. Among patients with high stroke risk (CHADS 2 ≥2) and low bleeding risk (ATRIA 0–3), 42–82% did not receive an antithrombotic. Conclusion: Levels of thromboprophylaxis for high-risk AF patients in real-world data differ significantly from current medical guidelines for stroke prevention.

We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and patients with AF are at an increased risk for stroke. Thromboprophylaxis with vitamin K antagonists reduces the annual incidence of stroke by approximately 60%, but appropriate thromboprophylaxis is prescribed for only approximately 50% of eligible patients. Health plans may help to improve quality of care for patients with AF by analyzing claims data for care improvement opportunities.To analyze pharmacy and medical claims data from a large integrated commercial database to determine the risk for stroke and the appropriateness of anticoagulant use based on guideline recommendations for patients with AF.This descriptive, retrospective claims data analysis used the Anticoagulant Quality Improvement Analyzer software, which was designed to analyze health plan data. The data for this study were obtained from a 10% randomly selected sample from the PharMetrics Integrated Database. This 10% sample resulted in almost 26,000 patients with AF who met the inclusion criteria for this study. Patients with a new or existing diagnosis of AF between July 2008 and June 2010 who were aged ≥18 years were included in this analysis. The follow-up period was 1 year. Demographics, stroke risk level (CHADS2 and CHA2DS2-VASc scores), anticoagulant use, and inpatient stroke hospitalizations were analyzed through the analyzer software.Of the 25,710 patients with AF (CHADS2 score 0-6) who were eligible to be included in this study, 9093 (35%) received vitamin K antagonists and 16,617 (65%) did not receive any anticoagulant. Of the patients at high risk for stroke, as predicted by CHADS2, 39% received an anticoagulant medication. The rates of patients receiving anticoagulant medication varied by age-group-16% of patients aged65 years, 22% of those aged 65 to 74 years, and 61% of elderly ≥75 years. Among patients hospitalized for stroke, only 28% were treated with an anticoagulant agent in the outpatient setting before admission.Our findings support the current literature, indicating that many patients with AF are not receiving appropriate thromboprophylaxis to counter their risk for stroke. Increased use of appropriate anticoagulation, particularly in high-risk patients, has the potential to reduce the incidence of stroke along with associated fatalities and morbidities.

Objective: Venous thromboembolism - deep vein thrombosis (DVT) and pulmonary embolism (PE) - affects an estimated 900,000 individuals, and is responsible for as many as 100,000 deaths each year in the US. Patients with a history of DVT/PE have heightened risk of recurrence. Initial parenteral anticoagulation (low molecular weight heparin [LMWH]) is standard treatment for acute DVT/PE followed by ≥3 months of warfarin, which itself introduces the risk of major bleeding. Balancing the increased risks of major bleeding and recurrent DVT/PE remains a challenge. Recent clinical trials show that rivaroxaban, an oral direct inhibitor of factor Xa, is as effective as standard therapy for acute DVT/PE and, when continued into the outpatient setting, may provide an effective, safe, single-drug, and simplified approach to treatment. We consider the economic implications of these data in the context of a commercial health plan. Methods: We used a decision-analytic model to estimate the annual economic burden of DVT/PE to a hypothetical commercial plan. Hospital days, acute and 1 year cost were assessed. The baseline scenario assumes that all patients with DVT/PE receive standard treatment (LMWH/warfarin). A projected scenario assumes that 75% of patients receive standard treatment, and 25% are treated with rivaroxaban. Rates of major bleed, non-major bleed, and recurrent DVT/PE events in the year following the acute DVT/PE are drawn from clinical trials. DVT/PE prevalence and healthcare costs are estimated based on published literature. Results: In a hypothetical plan of 1 million, our baseline model projects that management of acute DVT/PE (standard treatment) would consume 12,786 inpatient days (69% associated with DVT; 31% with PE) and $59.6 million (2013 USD). Treatment for 74 recurrent DVT/PE events (84% DVT) would cost $1.4 million; major bleed events (39; 64% DVT) and non-major bleed events (207; 70% DVT) would require an additional $1 million to treat. In the projected scenario, a 25% shift to oral anticoagulation with rivaroxaban reduced the number of inpatient days for acute management of DVT/PE to 11,753 (67% DVT), a reduction of 1,033 days (8%). Associated acute care costs totaled $57.7 million (73% DVT), a reduction of $1.9 million (3%). Overall, recurrent DVT/PE events and costs decreased by 6% (4 events; $82,000). In the projected scenario, 4 (10%) major bleeding events were prevented, at the cost of 1 (0.5%) additional non-major bleeding event which, taken together, reduced net healthcare utilization to manage bleeding events by about $91,000. Conclusion: Our model suggests that the reduction in inpatient utilization, recurrent DVT/PE events, and major bleed events resulting from a shift of 25% from standard therapy to oral anticoagulation with rivaroxaban following an acute DVT/PE event would generate about $2 million in savings for every 1 million patients enrolled in a commercial health plan.

Some 3 million people in the United States have atrial fibrillation (AF). Without thromboprophylaxis, AF increases overall stroke risk 5-fold. Prevention is paramount as AF-related strokes tend to be severe. Thromboprophylaxis reduces the annual incidence of stroke in AF patients by 22%–62%. However, antithrombotics are prescribed for only about half of appropriate AF patients. The study team estimates the economic implications for Medicare of fewer stroke events resulting from increased thromboprophylaxis among moderate- to high-risk AF patients. The decision model used considers both reduced stroke and increased bleeding risk from thromboprophylaxis for a hypothetical cohort on no thromboprophylaxis (45%), antiplatelets (10%), and anticoagulation (45%). AF prevalence, stroke risk, and stroke risk reduction are adjusted for age, comorbidities, and anticoagulation/antiplatelet status. Health care costs are literature based. At baseline, an estimated 24,677 ischemic strokes, 9127 hemorrhagic strokes, and 9550 bleeding events generate approximately $2.63 billion in annual event-related health care costs to Medicare for every million AF patients eligible for thromboprophylaxis. A 10% increase in anticoagulant use in the untreated population would reduce stroke events by 9%, reduce stroke fatalities by 9%, increase bleed events by 5%, and reduce annual stroke/bleed-related costs to Medicare by about $187 million (7.1%) for every million eligible AF patients. A modest 10% increase in the use of thromboprophylaxis would reduce event-related costs to Medicare by 7.1%, suggesting a compelling economic motivation to improve rates of appropriate thromboprophylaxis. New oral anticoagulants offering better balance between the risks of stroke and major bleeding events may improve these clinical and economic outcomes. (Population Health Management 2014;17:159–165)