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Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach

Haller, Matthew D; Cho, Hyung J; Ahn, Jennifer; Krouss, Mona; Alaiev, Daniel; Yoon, Garrett H; Dunn, Andrew S; Fagan, Ian
BACKGROUND:While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. OBJECTIVE:We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. DESIGNS, SETTINGS AND PARTICIPANTS/UNASSIGNED:A quality improvement initiative was implemented across 11 safety net hospitals in New York City. INTERVENTION/METHODS:The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. RESULTS:Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.
PMID: 37051635
ISSN: 1553-5606
CID: 5464232

Remdesivir for the Treatment of Covid-19 - Final Report

Beigel, John H; Tomashek, Kay M; Dodd, Lori E; Mehta, Aneesh K; Zingman, Barry S; Kalil, Andre C; Hohmann, Elizabeth; Chu, Helen Y; Luetkemeyer, Annie; Kline, Susan; Lopez de Castilla, Diego; Finberg, Robert W; Dierberg, Kerry; Tapson, Victor; Hsieh, Lanny; Patterson, Thomas F; Paredes, Roger; Sweeney, Daniel A; Short, William R; Touloumi, Giota; Lye, David Chien; Ohmagari, Norio; Oh, Myoung-Don; Ruiz-Palacios, Guillermo M; Benfield, Thomas; Fätkenheuer, Gerd; Kortepeter, Mark G; Atmar, Robert L; Creech, C Buddy; Lundgren, Jens; Babiker, Abdel G; Pett, Sarah; Neaton, James D; Burgess, Timothy H; Bonnett, Tyler; Green, Michelle; Makowski, Mat; Osinusi, Anu; Nayak, Seema; Lane, H Clifford; Ahn, Jenny; Ahuja, Neera; Alaaeddine, Ghina; Ali, Farhana; Amin, Alpesh N; Angus, Brian; Antoniadou, Anastasia; Arguinchona, Christa; Arguinchona, Henry; Atmar, Robert L; Babiker, Abdel G; Barmparessou, Zafeiria; Beigel, John H; Bell, Taison D; Benfield, Thomas; Benson, Constance A; Billings, Joanne; Boesecke, Christoph; Bonnett, Tyler; Branche, Angela R; Burgess, Timothy H; Cantos, Valeria D; Cao, Huyen; Chambers, Susan E; Chary, Aarthi; Chrysanthidis, Theofilos; Chu, Helen Y; Chung, Kevin K; Cohen, Stuart H; Colombo, Christopher J; Colombo, Rhonda E; Creech, C Buddy; Crouch, Pierre-Cedric B; Davey, Richard T; Dempsey, Walla; Dierberg, Kerry; Dodd, Lori E; Duncan, Christopher J A; Eckhardt, Benjamin; El Sahly, Hana M; Elsafy, Mohamed; Engel, Theresa; Erdmann, Nathaniel; Falsey, Ann R; Fatkenheuer, Gerd; Ferreira, Jennifer L; Finberg, Robert W; Follmann, Dean; Frank, Maria; Ganesan, Anuradha; George, Sarah L; Germain Seymour, Jack David; Gerstoft, Jan; Gettinger, Nikki; Gioukari, Vicky; Goepfert, Paul; Goodman, Anna; Green, Margaret; Green, Michelle; Grein, Jonathan; Grossberg, Robert; Helleberg, Marie; Hewlett, Angela; Hohmann, Elizabeth; Holodniy, Mark; Hsieh, Lanny; Huprikar, Nikhil; Hynes, Noreen A; Jackson, Patrick E H; Jang, Hannah; Javeri, Heta; Jensen, Tomas; Jilg, Nikolaus; Johansen, Isik; Jung, Jongtak; Jurao, Robert; Kalil, Andre C; Kalomenidis, Ioannis; Kim, Eu Suk; Kline, Susan; Knudsen, Lene; Koehler, Philipp; Koo, Hyung; Kortepeter, Mark G; Kotloff, Karen L; Koulouris, Nikolaos; Krueger, Karen; Lalani, Tahaniyat; Lane, H Clifford; Larson, LuAnn; Lee, Marina; Lee, Tida; Lindegaard, Birgitte; Lindholm, David A; Llewelyn, Martin; Lopez de Castilla, Diego; Luetkemeyer, Annie; Lundgren, Jens; Lye, David Chien; Madsen, Lone W; Makowski, Mat; Malin, Jakob J; Marks, G Lynn; Martinez-Orozco, Jose Arturo; Mateu, Lourdes; Maves, Ryan C; McGill, Fiona; McLellan, Susan L F; Mehta, Aneesh K; Mende, Katrin; Merrick, Blair; Metallidis, Simeon; Mikami, Ayako; Minton, Jane; Munoz, Jose; Nadeau, Kari; Nayak, Seema; Neaton, James D; Neumann, Henry J; Nielsen, Henrik; Nomicos, Effie; Noren, Brooke; Novak, Richard M; Oh, Myoung-Don; Ohmagari, Norio; Ong, Sean W X; Ortiz, Justin R; Osinusi, Anu; Ostergaard, Lars; Paredes, Roger; Park, Wan Beom; Patterson, Thomas F; Paules, Catharine I; Pett, Sarah; Philips, Barbara; Pikaart-Tautges, Rhonda; Ponce de Leon, Alfredo; Price, D Ashley; Proschan, Michael; Protopapas, Konstantinos; Rajme, Sandra; Regalado Pineda, Justino; Rice, Todd W; Riedo, Francis X; Riska, Paul F; Roldan, Montserrat; Rouphael, Nadine G; Ruiz-Palacios, Guillermo M; Sauer, Lauren M; Short, William R; Staerke, Nina; Stephan, Christoph; Stephens, David S; Sutterwala, Fayyaz; Sweeney, Daniel A; Swiatlo, Edwin; Taiwo, Babafemi; Tapson, Victor; Tebas, Pablo; Tennant, Janice; Thompson, George R 3rd; Thomsen, Isaac; Tomashek, Kay M; Torgersen, Jessie; Torres-Soto, Mariam; Touloumi, Giota; Traenkner, Jessica J; Utz, Gregory C; Uyeki, Timothy M; Van Winkle, Jason W; Voell, Jocelyn D; Vu, Trung; Wald, Anna; Walker, Robert; Walter, Emmanuel B; Wang, Jennifer P; Wang, Jing; Wasmuth, Jan-Christian; Weise, Lothar; Wendrow, Andrea; Wessolossky, Mireya; Whitaker, Jennifer; Widmer, Kyle; Wierzbicki, Michael R; Wolf, Timo; Wolfe, Cameron; Wolff, Peter; Yang, Otto O; Young, Heather; Zakynthinos, Spyros G; Zingman, Barry S
BACKGROUND:Although several therapeutic agents have been evaluated for the treatment of coronavirus disease 2019 (Covid-19), no antiviral agents have yet been shown to be efficacious. METHODS:We conducted a double-blind, randomized, placebo-controlled trial of intravenous remdesivir in adults who were hospitalized with Covid-19 and had evidence of lower respiratory tract infection. Patients were randomly assigned to receive either remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for up to 9 additional days) or placebo for up to 10 days. The primary outcome was the time to recovery, defined by either discharge from the hospital or hospitalization for infection-control purposes only. RESULTS:A total of 1062 patients underwent randomization (with 541 assigned to remdesivir and 521 to placebo). Those who received remdesivir had a median recovery time of 10 days (95% confidence interval [CI], 9 to 11), as compared with 15 days (95% CI, 13 to 18) among those who received placebo (rate ratio for recovery, 1.29; 95% CI, 1.12 to 1.49; P<0.001, by a log-rank test). In an analysis that used a proportional-odds model with an eight-category ordinal scale, the patients who received remdesivir were found to be more likely than those who received placebo to have clinical improvement at day 15 (odds ratio, 1.5; 95% CI, 1.2 to 1.9, after adjustment for actual disease severity). The Kaplan-Meier estimates of mortality were 6.7% with remdesivir and 11.9% with placebo by day 15 and 11.4% with remdesivir and 15.2% with placebo by day 29 (hazard ratio, 0.73; 95% CI, 0.52 to 1.03). Serious adverse events were reported in 131 of the 532 patients who received remdesivir (24.6%) and in 163 of the 516 patients who received placebo (31.6%). CONCLUSIONS:Our data show that remdesivir was superior to placebo in shortening the time to recovery in adults who were hospitalized with Covid-19 and had evidence of lower respiratory tract infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; ACTT-1 ClinicalTrials.gov number, NCT04280705.).
PMID: 32445440
ISSN: 1533-4406
CID: 4637302