A gap exists between clinical practice guidelines and real-world practice. We aim to investigate hospital admissions among patients presenting to emergency departments of 11 hospitals with venous thromboembolism (VTE). Eligible patients’ first emergency department VTE visit were retrospectively collected between 2013 and 2018 from electronic medical records (EMR). Patients were categorized at low risk of VTE complications if they were diagnosed with deep vein thrombosis (DVT) of the leg or if they were diagnosed with pulmonary embolism (PE) and had a PE score index < 85. Multivariable logistic regression models were constructed to measure the adjusted odds ratios (OR) and 95% confidence intervals (CI) of hospital admissions before and after clinical practice guidelines were updated to recommend outpatient management of DVT and PE with low risk of complications. A total of 13,677 patients were included in the analysis, of which 55% were diagnosed with DVT. Mean age was 65  ±  17 years, 54% were females, and 62% were Caucasian. Overall, 9281 patients were categorized at low risk VTE complications, of whom 77% were admitted for in-hospital management. The rate of in-hospital management declined from 81% in 2013 to 73% in 2018. Patients visiting emergency departments between 2016 and 2018 (post-guidelines) were equally likely to be admitted compared to patients visiting the emergency departments between 2013 and 2015 (pre-guidelines; OR = 0.99; 95% CI: 0.88, 1.11). Results from this real-world study indicate that most low-risk VTE patients are admitted for in-hospital management, despite recommendations in clinical practice guidelines.

RA patients with positive anti-CCP antibodies had higher degrees of inflammation and disease activity as indicated by laboratory results, which likely contributed to their higher rates of healthcare utilization, joint erosion, and proportions of RA treatment.

BackgroundCurrent management of rheumatoid arthritis (RA) in the United States is often directed by payer medical policy, typically requiring a tumour necrosis factor-α inhibitor (TNFi) as a first-line (1L) biologic disease-modifying antirheumatic drug (bDMARD). Recent studies1 suggest clinical subsets of patients with RA may benefit from early intervention with a non-TNFi bDMARD.ObjectivesTo characterise 6 month healthcare resource utilisation (HRU) for patients with RA in the United States when treated with different 1L bDMARDs (1L TNFi or 1L abatacept) and assess the impact of initial bDMARD selection on 6 month HRU.MethodsEarly, rapidly progressive RA (eRPRA) is a recognised clinical entity comprising a constellation of clinical and biomarker features: anti-cyclic citrullinated peptide-2 positivity (ACCP+), DAS28 (CRP) ≥3.2, symptomatic synovitis in ≥2 joints for ≥8 weeks and onset of symptoms≤2 years. Physicians with adult RA patients meeting these criteria for eRPRA used patient medical records to provide patient data via an electronic case report form. Patients received either abatacept or TNFi in 1L. Patient characteristics and HRU in the first 6 months of bDMARD treatment were summarised and compared across treatment groups. Odds ratios (OR) of HRU were estimated using multivariable logistic regression to adjust for baseline indicators of disease severity and patient mix (age, sex, race, ethnicity, region, payer type, time from RA diagnosis to bDMARD start, baseline concomitant medication use, baseline swollen joint count [SJC], tender joint count [TJC], Clinical Disease Activity Index [CDAI], extra-articular manifestations).ResultsThere were 60 abatacept and 192 TNFi patients in 1L. Mean ages at bDMARD start were 49.1 and 49.9 years, and mean times from RA diagnosis to bDMARD initiation were 1.5 and 6.4 months for abatacept and TNFi users, respectively (all p>0.05). At bDMARD start, patients with eRPRA treated with abatacept or TNFi, respectively, had mean SJC of 6.8 and 7.3, TJC of 10.4 and 10.2, ESR of 39.8 and 44.0 mm/h, CRP of 8.1 and 8.2 mg/L and numbers of bony erosions of 1.2 and 1.7 (all p>0.05). 45% and 47% (p>0.05) of abatacept and TNFi users, respectively, had concomitant oral corticosteroids at bDMARD start. A lower proportion of patients treated with abatacept had hospitalizations (72 vs 88%), emergency department (ED) visits (75 vs 90%) and MRI (65 vs 82%) (all p<0.05), while use of ultrasound (82 vs 88%) and radiography (88 vs 93%) during the first 6 months of bDMARD treatment was similar. After adjusting for patient characteristics, those treated with 1L abatacept had significantly lower odds of hospitalisation (OR 0.42; 95% CI 0.18, 0.95), ED visits (OR 0.39; 95% CI 0.16, 0.93) and MRI (OR 0.45; 95% CI 0.21, 0.97) compared with 1L TNFi (all p<0.05). Adjusted odds of achieving CDAI low disease activity within 100 days of bDMARD favoured 1L abatacept vs 1L TNFi (OR 3.26; 95% CI 1.32, 8.07; p<0.05).ConclusionsAfter adjusting for baseline disease severity, patients treated with 1L abatacept ...

Background: Venous thromboembolism (VTE) is often diagnosed in the emergency department (ED), but adherence to clinical guidelines in the management of VTE in the ED may be low. The 2016 update of the American College of Chest Physicians (CHEST) guidelines has recommended home management or early discharge instead of in-hospital treatment for patients with low risk VTE. Gaps in clinical practice and clinical guideline recommendations need to be identified to improve VTE management in the ED. Objectives: To investigate changes in management of patients with low-risk VTE who received a diagnosis in the ED before and after the February 2016 update of CHEST guidelines on antithrombotic therapy for VTE. Methods: This retrospective analysis examined patient electronic medical records from January 1, 2013 to December 31, 2018 from a large healthcare system in Illinois. Data were collected on patients presenting in 11 EDs in community hospitals who were given a primary diagnosis or discharge diagnosis of VTE based on International Classification of Diseases, Ninth Revision or Tenth Revision. VTE was categorized as low-risk if diagnosis was either lower-extremity DVT or PE and a pulmonary embolism score index (PESI) lower than 85. A multivariable logistic regression model was constructed to measure the adjusted odds of hospital admissions among patients with low-risk VTE before and after the update of the CHEST guidelines. The model was adjusted for patient demographics and clinical characteristics, type of anticoagulant administered, preexisting comorbidities, and hospital characteristics. Results: Among 2,193,965 ED visits over the 6-year period, 15,543 visits representing 14,530 patients who received diagnoses of DVT (55%) or PE (45%) were included in the analysis. The mean age was 65.0 ± 17.4 years, with 46% being male and 63% Caucasian. A total of 83% of patients with DVT were considered low risk based on DVT location and 49% of patients with PE were low risk based on PESI. The rates of hospital admission for management of low-risk VTE declined from 81% in 2013 to 73% in 2018. In the adjusted model, patients visiting EDs between 2016 and 2018 (post-update of guidelines) were equally likely to be admitted compared with patients visiting EDs between 2013 and 2015 (pre-update of guidelines; odds ratio [OR]=0.91; 95% confidence interval [CI]: 0.81, 1.02). Patients who received a diagnosis of PE compared with DVT (OR=4.90; 95% CI: 4.26, 5.64) and patients who received vitamin K antagonists compared with direct oral anticoagulants (OR=1.74; 95% CI: 1.54, 1.96) had higher odds of hospital admission. However, the presence of a pharmacist was associated with lower odds of hospital admission (OR=0.68; 95% CI: 0.55, 0.85). Conclusions: Our study results indicate that most patients receiving a diagnosis of low-risk VTE in EDs were admitted for in-hospital management despite clinical guidelines recommending otherwise. The 2016 update of CHEST guidelines recommending outpatient management had minimal effects on decreasing the rate of admissions of patients with low-risk VTE. More effort in real-world practices is needed to adopt guideline recommendations and integrate clinical evidence on new and existing treatment advances. Disclosures Rhoades: Bristol-Meyers Squibb: Research Funding. Khatib:National Institutes of Health: Research Funding; Bristol-Meyers Squibb: Research Funding; Takeda: Research Funding. Nitti:Takeda: Research Funding; Bristol-Meyers Squibb: Research Funding. McDowell:Bristol-Meyers Squibb: Research Funding. Szymialis:Bristol-Meyers Squibb: Employment. Blair:Takeda: Research Funding; Bristol-Meyers Squibb: Research Funding; National Institutes of Health: Research Funding.

Conclusions: Results show that despite a high-intensity intervention, half the FLS patients will have an intermediate or low FU compliance pattern. This is important in the context of secondary prevention where subsequent FF risk is increased. Investigating the behavioural patterns of FU compliance with patient-centered research may help understand this phenomenon.