Impact of Electronic Chronic Pain Questions on patient-reported outcomes and healthcare utilization, and attitudes toward eCPQ use among patients and physicians: prospective pragmatic study in a US general practice setting

OBJECTIVE: The Electronic Chronic Pain Questions (eCPQ) has been developed to help healthcare providers systematically capture chronic pain data. This study evaluated the impact of using the eCPQ on patient-reported outcomes (PROs) and healthcare resource utilization (HCRU) in a primary care setting, and patient and physician perceptions regarding use of, and satisfaction with, the eCPQ. METHODS: This was a prospective pragmatic study conducted at the Internal Medicine clinic within the Henry Ford Health (HFH) Detroit campus between June 2017 and April 2020. Patients (aged ≥18 years) attending the clinic for chronic pain were allocated to an Intervention Group to complete the eCPQ in addition to regular care, or a control group to receive regular care only. The Patient Health Questionnaire-2 and a Patient Global Assessment were assessed at baseline, 6-months, and 12-months study visits. HCRU data were extracted from the HFH database. Telephone qualitative interviews were conducted with randomly selected patients and physicians who used the eCPQ. RESULTS: Two hundred patients were enrolled, 79 in each treatment group completed all 3 study visits. No significant differences (p \u3e 0.05) were found in PROs and HCRU between the 2 groups. In qualitative interviews, physicians and patients reported the eCPQ as useful, and using the eCPQ improved patient-clinician interactions. CONCLUSION: Adding the eCPQ to regular care for patients with chronic pain did not significantly impact the PROs assessed in this study. However, qualitative interviews suggested that the eCPQ was a well-accepted and potentially useful tool from a patient and physician perspective. By using the eCPQ, patients were better prepared when they attended a primary care visit for their chronic pain and the quality of patient-physician communication was increased

Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum

Coronavirus disease 2019 (COVID-19) is a viral infection that can, in severe cases, result in cytokine storm, systemic inflammatory response and coagulopathy that is prognostic of poor outcomes. While some, but not all, laboratory findings appear similar to sepsis-associated disseminated intravascular coagulopathy (DIC), COVID-19- induced coagulopathy (CIC) appears to be more prothrombotic than hemorrhagic. It has been postulated that CIC may be an uncontrolled immunothrombotic response to COVID-19, and there is growing evidence of venous and arterial thromboembolic events in these critically ill patients. Clinicians around the globe are challenged with rapidly identifying reasonable diagnostic, monitoring and anticoagulant strategies to safely and effectively manage these patients. Thoughtful use of proven, evidence-based approaches must be carefully balanced with integration of rapidly emerging evidence and growing experience. The goal of this document is to provide guidance from the Anticoagulation Forum, a North American organization of anticoagulation providers, regarding use of anticoagulant therapies in patients with COVID-19. We discuss in-hospital and post-discharge venous thromboembolism (VTE) prevention, treatment of suspected but unconfirmed VTE, laboratory monitoring of COVID-19, associated anticoagulant therapies, and essential elements for optimized transitions of care specific to patients with COVID-19

American College of Rheumatology Provisional Criteria for Clinically Relevant Improvement in Children and Adolescents With Childhood-Onset Systemic Lupus Erythematosus

10.1002/acr.23834ARTHRITIS CARE & RESEARCH715579-59

Use of apixaban and rivaroxaban in young adults with acute venous thromboembolism: a multi-center retrospective case series

Since 2012 four direct oral anticoagulants (DOAC) have been approved by the US Food and Drug Administration (FDA) for treatment of acute venous thromboembolism (VTE). Clinical trials comparing DOACs to warfarin included more than 13,500 patients. However, included patients were all age 39 years or older. We sought to describe real-world use of DOACs among young adults with acute VTE. Multi-center retrospective case series of young adult patients (age 18-40 years) at two large academic medical centers who initiated any DOAC for VTE therapy in 2015 or 2016. Thrombotic and bleeding events as well as off-label drug use were described using summary statistics. Fifty-seven patients were identified (63.2% female). One of the 57 patients (1.8%) had a thromboembolic event. Seven of the 57 patients (12.3%) experienced a bleeding event, one categorized as a major bleed and six being categorized as clinically relevant non-major bleeding. One of the ten (10%) patients receiving apixaban was not initiated on the FDA-recommended 10 mg twice daily for the first 7 days. Seven of the 47 (14.9%) patients receiving rivaroxaban were not initiated on the FDA-recommended 15 mg twice daily dosing for the first 21 days. Bleeding occurred in approximately 14% of young adult patients treated with DOAC therapy. However, only one patient had their DOAC discontinued due to a major bleeding event. Recurrence of DVT while on DOAC therapy was rare

PNS19 Design of study to assess impact of electronic chronic pain questions on patient-reported outcomes and healthcare utilization in a United States general practice setting

Gaps exist in capturing real world data for chronic pain, making it difficult for physicians to assess and monitor patients, and for healthcare organizations to understand prevalence, utilization trends, and the impact of diagnosis and treatment decisions for chronic pain patients. The Electronic Chronic Pain Questions (eCPQ) is a 14-item questionnaire developed and psychometrically validated to help providers capture relevant chronic pain data from the electronic health record (EHR). A prospective, randomized pragmatic study is underway to determine if utilizing the eCPQ within a primary care practice setting results in improved patient-reported function and overall improvement. The eCPQ is being self-administered immediately prior to patient visits to those in the intervention group. Answers are then reviewed by their physician during the visit. Other questionnaires, including the Brief Pain Inventory-Short Form (BPI-sf), Patient Global Assessment (PGA) and the Patient Health Questionnaire for Depression and Anxiety (PHQ-2 and PHQ-9) are being administered following the appointment in order not to influence the standard of care (SOC). Patients in both the intervention and control groups will be evaluated at baseline, 6 and 12 months for their chronic pain condition as per SOC. The main outcome is the BPI-sf interference score change from baseline to 6 months comparing the control and intervention groups, with the PGA scores at 6 months a co-primary endpoint. After both their 6 and 12-month visits the intervention group will be invited to complete a survey to assess ease of use, utility, feasibility, and satisfaction with the eCPQ and their perception of its impact on their care. Providers will also complete a similar survey towards the end of the study. A subset in the intervention arm will also be randomly assigned to participate in a qualitative interview to further explore patients’ perception of the eCPQ. Providers will also be interviewed

Aspirin and warfarin: A combination for everyone?

Introduction: The addition of aspirin (ASA) to warfarin increases the risk of serious bleeding. The purpose was to decrease unnecessary ASA use in patients on warfarin. Methods: Quality improvement initiative from single center results analyzed from Henry Ford Hospital, 1 of 6 anticoagulation clinics involved in the Michigan Anticoagulation Quality Improvement Imitative (MAQI$sup$2$/sup$). Institutional Review Board approval was obtained. Inappropriate use of aspirin was defined as any patient on warfarin and concomitant ASA without any of the following co-morbidities: coronary artery disease, peripheral artery disease, heart valve replacement, prior stroke, and left ventricular assist device (LVAD). For patients identified, an initial email was sent to the enrolling anticoagulation physician requesting a review to discontinue ASA. If no response was received within 7 days of a second email, the enrolling physician was called by one of the investigators using a standardized script. Results: Combined warfarin and aspirin use was found in 29.5% [95% CI 28.2-30.9] or 1348 of 4565 patients on warfarin in the anticoagulation clinic. Inappropriate ASA use was identified in 140 patients (10.4%; 95% CI 8.8-12.0). Of those 140 identified, 125 discontinued ASA per their provider (89.3%; 95% CI 84.2-94.4), reducing the number of patients inappropriately on ASA by 9.3% [95% CI 7.8%-10.9%]. Conclusions: Over one quarter of patients on warfarin are on ASA and approximately 10% of these patients with no clear indication. When providers are contacted with the information, the vast majority are receptive to stopping ASA which should decrease bleeding risk in this group of patients

Analysis of quality measures before and after switching care models in MAQI2 anticoagulation clinics

Introduction: There are various warfarin management models in the U.S. including: Physician Managed, Pharmacist Managed, Primary Nurse Model (in which patients are assigned to a specific nurse caseload), and the In-Basket Model (where patients are assigned to the next available nurse). We compared four sites in the Michigan Anticoagulation Quality Improvement Initiative (MAQI$sup$2$/sup$) that had switched from the In-Basket Model to the Primary Nurse Care Model. Methods: Using data from the MAQI$sup$2$/sup$ consortium, we compared distinct measures for warfarin patients managed by the In-Basket Model, followed by management via the Primary Nurse Care Model, each at 6 month intervals. Patients had at least 3 months of wafarin prior to the start of the measurement period. The number of days between the INR result and patient contact were counted. Warfarin dose adjustments were determined by calculating the number of dose changes per number of out-of-range INRs for which a next INR was available. Results: In the Primary Care Model, there was a decrease in time between INR results and nurse interaction with patients (1.4-2.1 v. 0.8-1.6, p = 0.001). Patients experienced fewer dose adjustments of any kind (67.0% v. 64.8%, p = 0.016), and fewer weekly dose changes (58.7% vs. 53.9%, p = 0.001) in the Primary Care Model. Conclusions: Use of the Primary Care Nurse Model for managing warfarin patients in the MAQI$sup$2$/sup$ consortium was associated with a decrease in the total number of warfarin dose changes, and a quicker response to INR results compared with patients managed by the In-Basket Model, suggesting that the Primary Care Nurse Model may be more efficient

Thromboembolic prevention and anticoagulant therapy during the COVID-19 pandemic: updated clinical guidance from the anticoagulation forum

Thromboembolism is a common and deadly consequence of COVID-19 infection for hospitalized patients. Based on clinical evidence pre-dating the COVID-19 pandemic and early observational reports, expert consensus and guidance documents have strongly encouraged the use of prophylactic anticoagulation for patients hospitalized for COVID-19 infection. More recently, multiple clinical trials and larger observational studies have provided evidence for tailoring the approach to thromboprophylaxis for patients with COVID-19. This document provides updated guidance for the use of anticoagulant therapies in patients with COVID-19 from the Anticoagulation Forum, the leading North American organization of anticoagulation providers. We discuss ambulatory, in-hospital, and post-hospital thromboprophylaxis strategies as well as provide guidance for patients with thrombotic conditions who are considering COVID-19 vaccination